RB 37 
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Medical Epitome Series 



CLINICAL DIAGNOSIS 



AN D 

URtNALYSIS 






ARNEILL 



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Copyright N°. 



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Zbe flfcebical Epitome Series. 

CLINICAL DIAGNOSIS 
AND URINALYSIS. 

A MANUAL FOR STUDENTS AND PRACTITIONERS. 



BY 

JAMES RAE AKNEILL, A.B., M.D., 

Professor of Medicine and Clinical Medicine in the University of Colorado ; Physician 
to the Denver County Hospital and St. Joseph's Hospital, Denver; Consultant 
to the Jewish Consumptives Relief Society , Denver; Member of the 
Advisory Board of St. Joseph's Hospital for Con- 
sumptives, Silver City, New Mexico. 

SERIES EDITED BY 
VICTOR COX PEDERSEN, A. M., M. D., 

Instructor in Surgery and Anesthetist and Instructor in Anesthesia at the New York Poly- 
clinic Medical School and Hospital ; Genito- Urinary Surgeon to the Out-Patient 
Departments of the New York and the Hudson Street Hospitals ; 
Anesthetist to the Roosevelt Hospital. 

ILLUSTRATED WITH 79 ENGRAVINGS AND 
1 COLORED PLATE. 




LEA BROTHERS & CO., 

PHILADELPHIA AND NEW YORK. 



LIBRARY of CONGRESS 
Two Copies decay**! 

MAV 11 J905 

CoDyrigiu uiiry 





aw 

.to* 



Entered according to Act of Congress, in the year 1905, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



| 

v 



ELECTROTYPED BY 
WESTCOTT II THOMSON, PHILADA, 



PRESS OF 
WM. J. DORNAN. PHILADA. 



AUTHOR'S PREFACE. 



The great importance of laboratory examinations in all 
branches of medicine and surgery has come to be universally 
recognized ; but the ability to put the methods into practice, 
and to derive the information they can give, has not yet been 
as widely acquired by the profession. This brief volume, 
covering the essentials, is intended to serve the needs of 
physicians and students rather than those of experts. 

The practical side of laboratory work in its relation to the 
diagnosis of disease is emphasized. Many of the time-con- 
suming quantitative analyses are intentionally omitted or 
merely mentioned. To be of value they should be made by 
experienced chemists. An attempt is made to explain fully 
the most important tests and procedures, and to anticipate 
many of the difficulties and mistakes of the inexperienced 
worker. No claim is made for originality or completeness. 
Many of the standard works have been freely consulted — 
such as Simon, Von Jaksch, Nichols, Ewing, Cabot, Musser, 
DaCosta, Vierordt, Purdy, Peyer, Osier, and others. 

Numerous practical suggestions also have been obtained 
from the work in the clinical laboratory of the University 
of Michigan as instituted by Drs. Dock and Cowie. I am 
greatly indebted to Mr. Charles L. Bliss, late instructor in 
physiological chemistry in the University of Michigan, now 
government physiological chemist at Manila, for very valua- 
ble aid in the preparation of the section on Urinalysis. 

J. R. A. 

Denver, Colorado. 

3 



EDITOR'S PREFACE, 



In arranging for the editorship of The Medical Epitome 
Series the publishers established a few simple conditions, 
namely, that the Series as a whole should embrace the entire 
realm of medicine ; that the individual volumes should au- 
thoritatively cover their respective subjects in all essentials ; 
and that the maximum amount of information, in letter- 
press and engravings, should be given for a minimum price. 
It was the belief of publishers and editor alike that brief 
Avorks of high character would render valuable service not 
only to students, but also to practitioners who might wish 
to refresh or supplement their knowledge to date. 

To the authors the editor extends his heartiest thanks for 
their excellent work. They have fully justified his choice 
in inviting them to undertake a kind of literary task which 
is always difficult — namely, the combination of brevity, clear- 
ness, and comprehensiveness. They have shown a consistent 
interest in the work and an earnest endeavor to cooperate 
with the editor throughout the undertaking. Joint effort of 
this sort ought to yield useful books, brief manuals as con- 
tradistinguished from mere compends, 



6 EDITOR'S PREFACE. 

In order to render the volumes suitable for quizzing, and 
yet preserve the continuity of the text unbroken by the 
interpolation of questions throughout the subject-matter, 
which has heretofore been the design in books of this type, 
all questions have been placed at the end of each chapter. 
This new arrangement, it is hoped, will be convenient alike 
to students and practitioners. 

V. €. P. 
New York, 1905, 



CONTENTS. 



CHAPTER I. 

Pages 
General Considerations 17-23 



CHAPTER II. 
Blood ... 23-34 

CHAPTER III. 
Clinical Examination of the Blood 34-48 

CHAPTER IV. 
Study of the Stained Spread 48-60 

CHAPTER V. 
Pathological Conditions of the Blood 60-63 

CHAPTER VI. 

The Widal Reaction 64-67 

CHAPTER VII. 

Less Frequently Applied Procedures 68-104 

CHAPTER VIIL 

The Stomach 104-129 

7 



8 CONTENTS. 



CHAPTER IX. 

PAGES 

The Faeces 130-147 



CHAPTER X. 



Sputum 147-16.' 



CHAPTER XI. 
Miscellaneous Examinations 163-170 

CHAPTER XII. 
Urinalysis 170-191 

CHAPTER XIII. 
Examination op the Urine 191-215 

CHAPTER XIV. 
Urinary Sediments 215-238 



CLINICAL DIAGNOSIS AND URINALYSIS. 



CHAPTER I. 

GENEKAL CONSIDERATIONS. 

EQUIPMENT AND SCOPE OF WORK. 

In purchasing laboratory supplies one should deal with an 
absolutely reliable firm. Because of the technical skill and 
experience required in the preparation of some of the solu- 
tions and stains, it is well for beginners to purchase them 
already prepared. This statement refers especially to the 
decinormal sodium hydrate solution and the like, and such 
stains as Wright's, Gram's, and Ehrlich's triacid stains. 

Griibler's stains (powders) have the reputation of being the 
best on the market. 

Laboratory tables should be painted black. 

Laboratory diagnosis includes examination of the blood, 
stomach-contents, sputum, feces, urine, transudates and exu- 
dates, and of the various secretions and excretions of the body. 

Special apparatus and reagents are required for some of this 
work, but the same apparatus may be employed in many of 
the foregoing subdivisions. 

Among the general utility articles are to be mentioned the 
following : 

Microscope (triple nose-piece, 2 eye-pieces, 3 objectives) — 
i. e. y oil-immersion and high and low dry lens. 

Thermostat. 

Glass rods, different sizes. 

Glass tubing, different sizes. 

Filter-paper, 4 inch, 6 inch, 8 inch, etc. 

2— C. D. 17 



18 GENERAL CONSIDERATIONS. 

Funnels, different sizes (2 inch, 4 inch, etc.). 

Graduates, different sizes (100 c.c, 500 c.c, 1000 c.c). 

Centrifuge. 

Two-gallon syphon bottle with distilled water* 

Teasing needles. 

Platinum loop. 

Cover-glass forceps. 

File. 

Canada balsam (for mounting permanent specimens ; keep 
in wide-mouthed bottle). 

Turpentine. 

Cedar oil. 

Xylol. 

Glass slides — w T hite, not green glass. 

Cover-slips are sold in four thicknesses, Nos. 0, 1, 2, 3. 
No. 1 is best for general work, since it is thin enough for 
use with the oil-immersion lens, and is not so easily broken 
as No. 0. The square f-inch cover-glass should be used. 

Cleaning Glassware. — In cleaning glassware that has never 
been used, Cabot, after a long experience with various chem- 
icals, has given them up, and uses nothing but soap and 
water, with thorough polishing. 

The glassware may be placed in acetic acid for twenty-four 
hours, more or less (if in a hurry, a minute will do), then 
thoroughly washed in water and transferred to a large- 
mouthed bottle containing alcohol. When wanted, it is dried 
and polished with a clean soft cloth. 

The following cleaning fluid for glassware is recommended 
by Nichols as especially useful for glassware that has been 
soiled : 

Potassium bichromate, 10 parts ; 

Sulphuric acid (commercial), 10 " 

Water, 100 " 

The glassware is left in this fluid for twenty-four hours, 
then thoroughly rinsed with water and transferred to alcohol, 
to be used as wanted. 



EQUIPMENT AND SCOPE OF WORK. 19 

Carbol Fuchsin. — 

Fuchsin (S.), 1 part ; 

Absolute alcohol, 10 parts ; 

5 Der cent, solution of carbolic acid, 100 " 



Lbffler's Methylene-blue. — 

Concentrated alcoholic solution of methylene-blue, 30 parts ; 
1 : 10,000 aqueous solution of potassium hydrate, 100 " 

Gram's method requires the following solutions : 

1. Aniline Water. — Prepare by adding aniline oil to 10 c.c. 
of distilled water, drop by drop, shaking thoroughly after the 
addition of each drop, until the solution becomes opaque. 
Filter through moistened filter-paper. 

2. Aniline Water Gentian-violet. — Treat the foregoing solu- 
tion with 10 c.c. of absolute alcohol and 11 c.c. of a concen- 
trated alcoholic solution of gentian-violet. This combined 
solution keeps only a few days, and should, therefore, be made 
up fresh. 

3. LugoVs Solution. — 

Iodine, 1 part ; 

Potassium iodide, 2 parts ; 

Water, 300 " 

Gram's method is employed for the differentiation of certain 
bacteria, especially the gonococcus, and for staining the cap- 
sule of diplococeus pneumonice and other germs. 

Application of Gram's Method. — 1. Cover spread with 
aniline water gentian-violet (made within two weeks) and 
heat to steaming-point. 

2. Wash in water. 

3. Cover with LugoPs solution for one-half to two minutes 
to decolorize. 

4. Rinse in 95 per cent, alcohol until the violet color dis- 
appears to the naked eye. 

5. Wash in water and mount. 

When thus treated, certain bacteria retain the stain, such as 



20 GENERAL CONSIDERATIONS. 

diplococcus pneumoniae, diphtheria bacillus, tubercle bacillus, 
anthrax bacillus, streptococci and staphylococci. 

The bacteria which become decolorized are the following : 
gonococcus, typhoid bacillus, colon bacillus, influenza bacillus, 
and cholera spirillum. 

Fat-detection by Sudan III. — Test-solution. — Make a satu- 
rated alcoholic solution of Sudan III. Let stand for several 
days ; then mix 1 part of this solution with 1 part of alcohol 
and 1 part of water. The mixture is at once turbid, but clears 
on standing. Sudan III. stains fat red and leaves everything 
else unstained. Do not treat specimens with alcohol or ether 
before or after staining. 

Test — A drop or two of the solution is run under the cover- 
glass covering the specimen ; under the microscope the neutral 
fat is seen to take on a red color. 

Iodine Test for Starch. — Starch in granules or in solution 
strikes a deep-blue color in the presence of iodine. The stock 
test-solution is Lugol's. A drop or two of this solution is 
allowed to run under the cover-glass covering the specimen. 
In testing liquids for the presence of starch, dilute a few 
drops of this solution with water to a light-yellow color, and 
add a few drops of the suspected fluid. A deep blue indi- 
cates starch, a deep brown indicates erythrodextrin. 

Glycogen granules treated by the first method turn a deep 
mahogany brown under the microscope. 

Iodide Test for Starch. — Starch does not react to iodides in 
combination, but on setting free the iodine with nitric acid a 
deep-blue color develops. 

Technic. — A strip of starch-paper is moistened with the 
fluid to be tested and then touched with a drop of nitric acid. 
The characteristic blue color develops in the presence of 
iodides. 

Ethereal Extracts. — In certain tests the watery solution of 
the substance is shaken with ether or chloroform in order to 
extract the substance from the water. On standing the two 
fluids separate. Either the water or the ether may be re- 
moved by means of a pipette. Another method is to place 
the mixture in a filter which has been previously moistened 



EQUIPMENT AND SCOPE OF WORK. 21 

with water. The watery portion will then filter through. 
If ether is used for moistening the filter, the ethereal portion 
will filter through. 

Guaiacum Test for Blood. — To 4 or 5 c.c. of tincture of 
guaiacum add from ^ to \ as much hydrogen peroxide, or an 
equal amount of " ozonized" turpentine (expose turpentine to 
light and air for a long time). The suspected fluid — in a long 
glass tube placed at the bottom of a test-tube — is allowed to 
run slowly out and underlie the reagent. At the junction of 
the two liquids a robin's egg blue layer forms, either imme- 
diately or in the course of a few minutes, if hsemoglobin is 
present. 

Iodides and iodine also give a blue color. 

Hsemin Test for Blood. — A drop of a 0.6 per cent, salt solu- 
tion is evaporated on a slide. A small bit of the suspected 
materia], well teased, is placed upon the layer of crystallized 
salt. Place a cover-slip over it, and allow glacial acetic acid 
to run in under the slip, filling the spaces. Heat carefully 
(three-quarters to one minute) till bubbles of gas begin to form 

Fig. 1. 




Hsemin crystals. 

beneath the cover. During evaporation glacial acetic acid is 
further added, drop by drop, from the edge of the slip, until 
a faint reddish-brown tint appears. Now hold specimen farther 
away from the flame, and slowly evaporate the last traces 
of acid. Add a drop of glycerin and examine under the 
microscope. If blood is present, heemin (or Teichmann) crys- 
tals form, in the shape of light- or dark-brown rhombic plates 
or columns. The size of the crystals varies with the manner 
in which they are produced. The more slowly the acetic 
acid is evaporated the larger the crystals. 



22 



G ENSEAL CONSIDERATIONS. 



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BLOOD. 23 

It is often desirable to convert Centigrade (C.) into Fahren- 
heit (F.). The following formula will be found useful : 



QUESTIONS. 

Mention the various methods of cleansing glassware. 

Describe the method of preparing carbol-fuchsin and Loffler's methylene- 
blue. 

Describe Gram's stain, its practical application, and its special value. 

Describe a method for the detection of fat. 

What is the iodine test for starch ? 

What is meant by ethereal extracts ? 

Describe the guaiacum and hsemin tests for blood. 

Give the formulas for converting Fahrenheit into Centigrade, and vice 
versa. 



CHAPTER II. 

BLOOD. 

THE TECHNIC OF BLOOD- WORK-PRACTICAL 
SUGGESTIONS. 

Blood-Stickers. — The German blood-sticker, illustrated in 
Fig. 2, is the most satisfactory made ; it costs 50 cents. The 
pen-sticker costs 5 cents and is very good. A pen with one 
nib broken is a useful substitute. The Hagerdorn needle is 
also used by many. 

Gleaning Blood Pipettes. — In hospitals and laboratories 
where a great deal of blood-work is done an aspirator (Fig. 3) 
will be found extremely useful. 

The cold-water faucet is threaded and the appliance screwed 
on. A rather large bottle with a doubly perforated rubber cork 
is attached, on one side by noncollapsible rubber tubing to the 
aspirator, and on the other to the blood-counter. The water 
is turned on, and its rush through the aspirator produces a 
suction which is felt in the blood-counter. This instrument- 
is placed for a few seconds in a bottle of dilute acetic acid, 



24 



BLOOD, 



then in alcohol, and finally in ether, and these fluids sucked 
through it, thereby thoroughly cleaning and drying it. It is 



Fig. 2. 

A 




convenient to keep these four bottles grouped together in a 
rack. 

Common Method of Cleaning a Blood Pipette. — Remove the 
rubber tubing attached to the blood-counter. Apply the 

Fig. 3. 



<S*gfc3 




mouth and suck dilute acetic acid, alcohol, and ether through 
the pipette, thus cleaning and drying it. 



THE TECHNIC OF BLOOD-WORK. 25 

The dilute acetic acid and alcohol may be forced out by 
blowing through the pipette, but the ether must be expelled 
by forcible, downward, jerking movements of the hand, since 
moisture would be forced into it by the mouth. If clean and 
thoroughly dry, the glass ball in the bulb will roll about 
freely on moving the pipette. Compressed air furnishes a 
handy means for drying the pipette. 

Coagulated Blood in Pipette. — This accident occasionally 
happens to beginners because of slow manipulation. In order 
to remove the coagulum do not insert a needle or pen into the 
lumen, as there is danger of breaking off the tip of the instru- 
ment. It is best to place the pipette in a test-tube filled with 
sulphuric acid and allow it to digest the coagulum for twenty- 
four to forty-eight hours. Then pursue the ordinary method 
of cleaning. If this is not successful, as sometimes happens, 
break up the coagulum by the careful insertion of a fine hypo- 
dermatic wire. Even with careful routine cleansing a film of 
coagulated albumin is apt to adhere. This should occasion- 
ally be removed by cleansing with sulphuric acid. 

Rubber Tubing for Blood- counters. — Small rubber catheters 
are much better than the rubber tubing supplied with the 
blood pipettes. When thickening of Canada balsam occurs, it 
should be thinned with xylol. 

Cleansing Lenses. — Cedar oil should be removed from 
the oil-immersion lens immediately after using by touching it 
with filter-paper or rice-paper. It frequently happens that 
cedar oil dries on the objective, obscuring the field of vision. 
It may be removed by rubbing the lens with a soft cloth or 
absorbent cotton moistened with either alcohol or xylol. A 
camePs-hair brush is useful for dusting slides and cover-slips. 

Diluting Fluids for Counting Red Corpuscles. — 

Toisson's : 

Methyl-violet, 5 B, 0.025 gm. ; 

Sodii chlor., 1.000 gm.; 

Sodiisulph., 8.000 gm.; 

Neutral glycerin, 30.000 cm. ; 

Aqua dest., 160.000 cm. 



26 BLOOD. 

Gowers' : 

Sodii sulph., gr. cxij ; 

Acid, acet., 3v ; 

Aqua dest., §iv. 

Hayem's : 

Hydrarg. bichlor., 0.5 gm, 

Sodii sulph., 5.0 gm. 

Sodii chlor., 1.0 gm. 

Aqua dest., 200.0 gm. 

Toisson's fluid is most commonly used, but is dirty and de- 
posits considerable sediment. It should be filtered. Its only 
advantage is that it stains the white corpuscles and makes it 
possible to count them along with the red cells. However, 
if one has a white counter, the cells are best counted sepa- 
rately. 

Diluting Fluid for Counting Leukocytes.— 0.3 to 0.5 
per cent, of glacial acetic acid in distilled water. 

Wright's Stain. — (1) 0.5 per cent, solution of sodium bi- 
carbonate. Dissolve thoroughly. 

(2) To (1) add 1 per cent, of inethylene-blue (Griibler's 
B X or Ehi;lich ? s). 

(3) Steam (2) 1 hour in steam sterilizer. 

(4) Cool mixture. 

(5) Pour into large flask and add to it, stirring, enough 
1 : 1000 watery solution of eosin (Griibler yellow, water- 
soluble) until the mixture becomes purple in color, and a 
yellow metallic scum forms on the surface and a finely granu- 
lar precipitate appears in suspension. This takes about 500 
c.c. of eosin solution to 100 c.c. of alkaline solution. 

(6) Filter (5) ; do not wash ; let filter dry and collect dry 
powder. 

(7) With powder make a saturated solution in methyl alco- 
hol — i. e. } 0.3 gram in 100 c.c. of methyl alcohol. 

(8) Filter (7) and add to filtrate 25 per cent, of methyl 
alcohol. This is the staining fluid, 



THE TECHNIC OF BLOOD-WORK, 27 

The Ehrlich Tricolor Mixture. — 

Saturated watery solution of orange-green, 6 c.c. ; 
Saturated watery solution of acid fuchsin, 4 c.c. 

Mix these and then add a few drops at a time, shaking be- 
tween each addition, 

Saturated watery solution of methyl-green, 6.6 c.c. ; 

Then add : 

Glycerin, 5.0 c.c. ; 

Absolute alcohol, 10.0 c.c. ; 

Water, 15.0 c.c. 

Shake well for one to two minutes. Let stand for twenty- 
four hours. Do not filter. 

This formula is suggested by Cabot, though there are many 
other methods of making it. 

Eosin. — 

Eosin, 0.5 gram ; 

Alcohol (70 per cent.), 100.0 c.c. 

Hsematoxylon (Delafield's). — To 400 c.c. of a saturated 
solution of ammonium alum add 4 grammes of hsematoxylon 
crystals dissolved in 25 c.c. of strong alcohol. Leave this 
exposed to the light and air in an unstoppered bottle for three 
or four days. Filter and add 100 c.c. of methyl alcohol. 
Allow the solution to stand until the color is sufficiently dark. 
Then filter and keep in tightly stoppered bottles. The stain 
should ripen for at least two months before using. 

Eosin and Methylene-blue. — (a) A saturated alcoholic solu- 
tion of Ehrlich's blood eosin. (b) A saturated watery solu- 
tion (1 per cent.) of Ehrlich's rectified methylene-blue. The 
latter should be at least one week old. 

After several weeks, methylene-blue in solution diminishes 



28 BLOOD. 

in staining power, while the alcoholic eosin absorbs water and 
becomes less selective and more powerful. 

Ehrlich's Dahlia Solution. — 

Absolute alcohol, 50.0 c.c. ; 

Glacial acetic acid, 12.5 c.c. ; 

Distilled water, 100.0 c.c. 
Add dahlia to saturation. 

Iodophilia Mixture. — 

Iodi. sublim., 1 gm. ; 

Pot. iodidi, 3 gm. ; 

Aq. dest., 100 c.c. 
Acacia ad syrupum. 

Nocht-Romanowsky Stain for Malarial and other Parasites. — 
1 . To 1 ounce of polychrome methylene- blue (Grubler) add 
5 drops of a 3 per cent, solution of acetic acid (U. S. P., 33 
per cent.). 

2. Make a saturated 1 per cent, watery solution of methyl- 
ene-blue, preferably Ehrlich's (Grubler) or Koch's, dissolving 
the dye by gentle heat. This solution improves with age, 
and should be at least one week old. 

3. Make a 1 per cent, watery solution of Grubler's icatenj 
eosin. 

The mixture is prepared as follows : To 10 c.c. of water 
add 4 drops of the eosin solution, 6 drops of neutralized poly- 
chrome blue, and 2 drops of a 1 per cent, methylene-blue 
solution, mixing well. The specimens may be fixed either in 
alcohol or by heat, and are immersed, specimen side down- 
ward, for one to three hours, and will not overstain in twenty- 
four hours. 

THE BLOOD AS A WHOLE. 

The blood as a whole consists of a fluid portion, the plasma, 
in which are suspended cells of three kinds : red blood-cor- 



THE BLOOD AS A WHOLE. 29 

puscles (erythrocytes), white blood-corpuscles (leukocytes), and 
blood-plates. 

Total Volume.— Most text-books give the total volume of 
the blood as about one-thirteenth of the body weight. If the 
recent researches of Haldane and Smith prove to be trust- 
worthy, this deeply rooted idea will be modified. Smith 
estimates the average volume of blood in health as 3240 c.c., 
or 3420 grammes. In the 14 normal cases studied, the blood- 
mass varied from 2830 to 4550 grammes, or one-thirtieth to 
one-sixteenth of the body weight. A correct knowledge of 
the total blood volume would be of remarkable clinical value 
in diagnosing an anaemia and plethora. The methods 
employed by these observers will be referred to in another 
chapter. Unfortunately they are not sufficiently easy of appli- 
cation to be put into general use. 

Color. — The red color of the blood is due to an albumi- 
nous iron-containing substance called hcemoglobin, which is 
combined in the red blood-corpuscles. It has an extremely 
strong affinity for oxygen, combining with it to form oxy- 
hemoglobin. The excess of oxyhemoglobin in the arterial 
blood over that in the venous blood gives the former its 
bright-red color and the latter its bluish appearance. The 
hemoglobin of normal blood, represented by its red color, is 
arbitrarily placed at 100 per cent. The varying color of 
blood in disease is dependent upon the amount of hemoglobin 
and oxyhemoglobin present ; a great excess of the leukocytes, 
however, tends to give the blood a whitish or creamy appear- 
ance, such as is seen in leukemia. 

Reaction. — The reaction of the blood during life is alka- 
line, owing to the presence of disodium phosphate (Na 2 HP0 4 ) 
and sodium carbonate. It is lower in women and children 
than in men, and is influenced by physiological processes, 
such as digestion, exercise, etc. In a large number of patho- 
logical conditions it is diminished, such as the prolonged use 
of acids, and in pernicious anemia, leukemia, nephritis, 
diabetes, hepatic disease, carcinoma, high fevers, and toxic 
conditions. An increase in the alkalinity is brought about 
by the prolonged use of alkalies and by cold baths. 



30 BLOOD. 

Coagulation. — The most striking phenomenon which the 
blood exhibits on exposure to the air is the formation of a 
clot. If a bit of this clot be examined microscopically, it 
will be found to consist of a dense network of fibres which 
is filled with blood-corpuscles. These may be washed out, 
leaving the fibrin network intact. 

Fibrin belongs to the class of the so-called coagulated albu- 
mins, and probably does not occur in the circulating blood, 
but is formed during the process of coagulation. 

Blood-serum is the straw-colored fluid which separates 
from the clot during the process of coagulation. It differs 
from blood-plasma in the absence of fibrinogen and the pres- 
ence of large quantities of fibrin-ferment and traces of fibrino- 
globulin in the blood-serum. 

In the plasma the following albumins are found : fibrino- 
gen, serum-globulin, and serum-albumin. 

Agglutinins are very important constituents of the blood- 
serum ; they are susceptible to examination, and furnish 
valuable clinical information, as is seen in the Widal test in 
typhoid fever. They appear in the blood-serum as a result 
of bacterial infection, each variety of germ elaborating a 
special agglutinin, which has a specific agglutinating effect 
only upon that species of germs. 

Pigment-granules are sometimes present in the plasma, 
as in malaria, melanosis, and sometimes in Addison's dis- 
ease. 

Haemoglobin occasionally passes into solution in the blood- 
plasma — i. e. 9 hcemoglobincemia. 

The following additional substances are found in the blood : 
fats, soaps, cholesterin, sugar, glycogen, and at times lecithin. 
Numerous extractives have been found in the blood, such as 
urea, uric acid, kreatin, carbamic acid, sarcolactic acid, hip- 
puric acid, and, under pathological conditions, xanthin, hypo- 
xanthin, paraxanthin, adenin, guanin, leucin, tyrosin, lactic 
acid, cellulose, /9-oxybutyric acid, acetone, and biliary con- 
stituents. These numerous substances are of practically no 
clinical importance. 

Chemical analysis of the blood shows the following com- 



PHYSIOLOGY OP THE BLOOD. 31 

position, calculated for 1000 parts, according to the table of 
C. Schmidt : 

Man. Woman. 

Corpuscles 513.01 369.20 

Water 349.70 272.60 

Haemoglobin and globulins 159.60 120.10 

Mineral salts 3.70 3.55 

Plasma 486.90 603.80 

Water 439.00 552.00 

Fibrin 3.90 1.91 

Albumin and extractives 39.90 44.79 

Mineral salts 4.14 5.07 

Specific gravity of normal blood varies from 1056 to 
1060, being somewhat higher in men than in women. It 
varies greatly in disease, running practically parallel to the 
haemoglobin per cent. 

PHYSIOLOGY OF THE BLOOD. 

Examination of a fresh drop of normal blood under the 
microscope reveals chiefly two things, red corpuscles and 
white corpuscles ; less prominently blood-plates, Muller's 
" blood-dust," and a fibrin network. 

Red Corpuscles. — Under normal conditions the number 
of red corpuscles per cubic millimetre is quite constant, 
averaging about 5,000,000 in the male and 45,00,000 in thfc 
female. This number is greatly increased or diminished in dis- 
ease. In vigorous health the number often reaches 6,000,000. 
High altitudes increase the number of cells up to 8,000,000 
or 9,000,000. In the newborn the number of cells is high for 
a few days, 7,000.000 to 8,000,000. The red corpuscle is a 
round biconcave disk, with a yellowish or greenish-yellow 
appearance. It varies considerably in size under normal 
conditions, but the average may be taken as 7.5/^. It 
seems to be larger in northern than in southern latitudes. 
Red blood-cells are all of the same round shape, except as 
they are indented, bent, and curved by striking against each 
other, or against white corpuscles, as they are moved in the 
plasma-currents. These corpuscles tend to form rouleaux, 
rows of cells standing on end or slightly tilted, like piles of 



32 



BLOOl). 



coins. The cells also become crenated with great facility. 
One should become thoroughly familiar with all forms of 
crenation, since the early stage of this process produces a 
deceptive appearance in the cell, which resembles the young 
form of the malarial parasite. 

White corpuscles attract attention by their color, size, 
granules, amoeboid movements, or by the fact that they are 
not moved by the blood-current like the red cells. In 
healthy adults they vary considerably in number, averaging 



Fig. 4. 




Normal and abnormal red blood-corpuscles : a, Normal corpuscles, side and edge 
view; b, vacuole formation; c, crenated corpuscles; </, rouleau formation; r, pale 
corpuscles, deficient in haemoglobin;/, poikilocytes ; g, macrocyte ; h, microcyte; 
i, normoblast ; k, megaloblast. (Nichols.) 



about 7500 per cubic millimetre. The normal ratio of red 
to white cells is about 1 : 600. They vary much in size, from 
10 fjt to 13.5 /i, depending on the variety. 

Blood-plates are small irregularly shaped disks, about half 
the size of a red cell, and having a tendency to clamp in 
bunches. They are seldom noticed in normal unstained 
blood, probably because of slow manipulation. Their num- 
ber is variously estimated at from 180,000 to 860,000 per cubic 



PHYSIOLOGY OF THE BLOOD. 



33 



millimetre. They do not contain haemoglobin, and show no 
signs of a nucleus. 

Blood-dust. — Muller has given the name " hsemokonia " 
to small round colorless granules (\ to 1 [x in diameter) which 
may be found in normal and pathological blood. They are 
highly refractile, have a rapid dancing movement, but are 
without power of locomotion. 

Fig. 5. 




Normal blood. X 350. (Cabot.) 



Fibrin Network. — If a fresh blood-drop preparation 
is exposed to the air for some time, a network of fine 
fibrin threads forms, and may be seen under the microscope, 
running between the corpuscles and sometimes radiating from 
a centre which is perhaps a mass of blood-plates. Under cer- 
tain conditions this network is increased or diminished. 
3— c. D. 



34 CLINICAL EXAMINATION OF THE BLOOD. 

QUESTIONS. 

Describe the method of cleansing the blood pipette. 
How should coagulated blood be removed from the pipette? 
Describe the method of cleansing lenses. 

Mention the diluting fluids used in counting red and white blood-cor- 
puscles. 

Mention the important blood-stains. 

What is the total volume of blood in man ? 

The colors of the blood are due to what substance? 

What is the reaction of the blood and upon what does it depend? 

Upon what does the coagulation of the blood depend ? 

What is the specific gravity of the blood ? 

What are agglutinins? 



CHAPTER III. 

CLINICAL EXAMINATION OF THE BLOOD. 

PRELIMINARY REMARKS. 

A proper appreciation of blood-examinations and the cor- 
rect deductions to be drawn therefrom must take into account 
certain physiological and pathological laws. 

Among these factors may be mentioned abnormal dilata- 
tion or contraction of the peripheral bloodvessels, local anae- 
mias and congestions, concentration of the blood as in 
diabetes, and physiological variations for age and sex. Mus- 
cular exertion, profuse perspiration, ingestion of fluids, and 
temporary cyanosis alter the quality of the blood. 

The blood is also strikingly influenced by the nervous sys- 
tem acting through cerebral (psychical) or medullary centres, 
or through local vasomotor nerves. 

Therapeutic measures, such as the application of cold, heat, 
massage, electricity, aspiration of fluids, administration of 
purges, diaphoretics, vasodilators and vasoconstrictors, work 
like changes. 

Clinical Examination of the Blood includes the follow- 
ing Procedures. — 1. Examination of the fresh drop. 

2. Estimation of the percentage of haemoglobin. 

3. Estimation of the specific gravity. 

4. Counting the red corpuscles. 



PRELIMINARY REMARKS. 35 

5. Counting the white corpuscles. 

6. Study of the stained spread. 

7. Widal serum test, and — 

Less Frequently Applied Procedures. — 8. Estimation of the 
alkalinity. 

9. Estimation of the comparative volume of plasma and 
corpuscles. 

10. Estimation of the total volume of blood. 

11. Estimation of the time and completeness of coagula- 
tion. 

12. Bacteriological examination of the blood. 

13. Cryoscopic examination of the blood. 

The physician should use his judgment in deciding upon 
which or how many of these procedures must be carried out. 
Frequently the examination of the fresh drop is sufficient. 
Again, only haemoglobin estimation and red and w T hite counts 
will be found necessary. Other cases require, in addition to 
the above examination, careful study of the stained spread. 

The Widal test should be made only in suspected typhoid 
cases, and often is the only examination required. 

Method of Securing Blood. — The finger-tip or lobe of 
the ear is cleansed with alcohol or ether, or simply water, care 
being taken not to rub too briskly, as the local blood condi- 
tions may be altered by the massage. A cold, bloodless finger 
should not be chosen, since it does not represent the actual 
blood condition of the patient. If rubbing is necessary, 
sufficient time should elapse to allow the circulation to equalize. 
A moderately deep puncture should be made, so that only 
slight pressure will cause the blood to flow. 

Fresh Drop Examination. — 1. Macroscopical. — Its general 
appearance ; color, whether pale or red, streaked or creamy ; 
its manner of flow ; coagulation, rapid or slow. 

2. Microscopical. — This procedure is very simple. A thor- 
oughly cleansed and polished cover-slip is brought into con- 
tact at its centre with a small drop of blood directly it appears 
on the finger-tip. It is immediately dropped upon a clean 
slide. If the manoeuvre be properly done, the blood will spread 
over the whole cover-slip, leaving a film one corpuscle deep. 



36 CLINICAL EXAMINATION OF THE BLOOD. 

Success depends largely on cleanliness and quickness. If it 
be seen that the blood will not run well, slight pressure with 
the forceps will assist. 

Such preparations remain in good condition for several 
hours, since the periphery of the blood coagulates and seals 
the specimen. To preserve them longer, cover the borders 
with vaselin. 

This fresh drop preparation reveals a great many things to 
the experienced observer. He studies the color of the red 
corpuscles, their shape and size, the relative number of cells 
both red and white, the kind of white cells, the peculiarity of 
their granules, small or large, the amoeboid motion of leuko- 
cytes, the presence of rouleau formation, the approximate 
amount of fibrin, the relative number of blood-plates, and the 
presence of parasites. 

Estimation of the Haemoglobin. — Tallqyist Method. — 
This method is the most easily applied and gives fairly accu- 
rate results. In fact, ten Tallqvist estimations may be made 
in the time required for one Fleischl. It consists in the 
comparison of the color of a fresh drop of blood soaked up 
by a white filter-paper, and a scale of colors varying from 10 
to 100 per cent. The comparison must be made immediately 
after the drop has lost its moist appearance and before it 
dries. 

Extensive experience shows that the readings from Tallq- 
vist and Fleischl differ very little indeed, perhaps 3 to 7 per 
cent. 

Another instructive procedure is to compare a drop of 
blood from the patient with that from a full-blooded, healthy 
individual. The contrast is often striking, and a very 
close estimate may be made as to the percentage of haemo- 
globin. 

The use of the Fleischl haemoglobinometer has been the most 
accurate and practical method of estimating haemoglobin until 
the introduction of Miescher's modification of the Fleischl in- 
strument, and still later Dare's haemoglobinometer. 

Fleischl's Haemoglobinometer. — (a) This apparatus (Fig. 7) 
consists of a metal stand with plate and plaster mirror (S), 



PRELIMINARY REMARKS. 37 

which reflects diffused light through a circular opening in the 
plate. Beneath the plate, by means of a rack and wheel (T), 
slides a colored glass wedge fixed in a graduated frame (P). 
The glass wedge and graduated scale are so arranged as to 
indicate the percentage of Hb corresponding to the different 
portions of the wedge. In the circular opening of the plate 
fits a cylindrical metallic cell (Gr), with glass bottom and 

Fig. 6. 



Tallqvist's haemoglobin scale. 

metal partition, one compartment of which lies directly over 
the glass wedge. The other compartment (a) being filled 
with diluted blood, one is enabled to make a close compari- 
son of the color of the dissolved blood with that of the glass 
wedge. The blood is measured by an automatic capillary 
pipette, while a slowly running dropper is provided with 
which to add distilled water. On the handle of each pipette 
is stamped a number indicating its cubic contents. On the 



38 



CLINICAL EXAMINATION OF THE BLOOD. 



stand of each instrument is also a number showing the capacity 
of the tubes with which it can be used. 

(b) Procedure. — The pipette should be thoroughly clean 
and in working order. It is brought into contact with a drop 
of fresh blood expressed with very slight pressure, and should 
at once fill level-full. Do not immerse in the drop, or blood 
will adhere to the sides, thus furnishing one source of error. 

Fig. 7. 




Fleischl's hsemoglobinometer. 



The tube of blood is immediately transferred to a compart- 
ment half-filled with distilled water and swished about till 
the blood is dissolved. On removal a few drops of distilled 
water are allowed to run through the tube in order to remove 
any remaining haemoglobin. The blood is throughly mixed 
with the handle of the pipette. Both chambers are now filled 
even-full with distilled water. The thick round cover-glass 
is carefully adjusted, avoiding the inclosure of air and the 



PRELIMINARY REMARKS. 39 

forcing of dissolved blood from its chamber into that contain- 
ing only distilled water. 

The cover-glass need not be used if the reading is promptly 
made. It must be done in a dark room by means of candle 
or gaslight. The light is placed about eighteen inches from 
the stand. An improvised paper tube which exactly fits the 
cell is used to look through. With low percentages of Hb a 
dim light is essential. 

When the cell is in place and the light adjusted, the wedge 
is moved with quick turns till the colors in the two chambers 
exactly correspond. It is often useful to close the eyes and 
glance at the colors quickly, as a prolonged gaze tires the eye 
and makes it less accurate in the judgment of colors. When 
dealing with low percentages of haemoglobin it may be advisa- 
ble to use double the quantity of blood, as the matching of 
colors is more exact in the middle of the scale. An error of 
5 per cent, must be allow r ed. 

Miescher's Modification of Fleischl's Hsemoglobinometer. — 
This instrument (Fig. 8) gives more accurate results than any 
other. The blood is diluted with distilled water by means of 
a graduated pipette very similar to that of Thoma, dilutions of 
1 : 200, 1 : 300, and 1 : 400 being made according as the tube 
is filled with blood to the mark \, -§-, or 1 There are two 
cells, one with a depth of 15 mm., the other with a depth of 
12 mm. 

The percentage of haemoglobin is obtained with the deeper 
cell, the other being used as a control and giving only ^f of 
the actual percentage. These cells have a projecting partition 
dividing the compartments, along which a grooved cover-glass 
(D) may be slid without mixing the blood and water. The 
cells are covered with diaphragms, transmitting a ray of light 
which includes only 3 degrees on the scale, thus giving prac- 
tically a single color of the wedge to compare with the blood. 
The pipette is agitated thoroughly, mixing the haemoglobin, the 
diluting fluid blown from the tube, and one chamber in each cell 
is filled with the diluted blood, the other with distilled water. 
Cover-glasses and diaphragms are adjusted and the read- 
ings made. That of the small cell should be four-fifths that 



40 



CLINICAL EXAMINATION OF THE BLOOD. 



of the larger. These may be used to correct each other. 
A dilution of 1 : 200 is generally used. If the dilution is 
1 : 300, the reading must be multiplied by 1\ ; if 1 : 400, by 2. 

Oliver's Haemoglobinometer. — For the application of this 
method the reader is referred to Ewing or Cabot. 

Jolle's Ferrometer. — By means of this apparatus the iron in 
the blood is estimated, and with a formula the haemoglobin 




Miescher's hsemoglobinometer. 

calculated. The reader is again referred to Ewing or Cabot 
for a description of the method. 

Dare's haemoglobinometer is highly recommended by Cabot. 
At Johns Hopkins it has supplanted the older instruments. 
In it the undiluted blood is used. Blood is drawn by capil- 
lary attraction into the slit between two slabs of glass, one 
transparent, the other translucent and white, so as to diffuse 



PRELIMINARY REMARKS. 



41 



the light used for illumination. Its color is compared with 
different portions of a circular disk of colored glass. The 
readings are a trifle higher than those obtained with the 
Fleischl instrument. Full directions accompany each appa- 
ratus. Its cost (twenty dollars), its bulk, and the time taken 
for cleansing, make it much less practical than Tallqvist's 
apparatus. 

Color-index. — By this term is meant the ratio existing be- 
tween the haemoglobin per cent, and that of the red cells, on 
the basis of 5,000,000 red cells equalling 100 per cent, of 



Fig. 9. 




Dare's hsemoglobinometer. 

haemoglobin. By this rule 1,000,000 red cells should corre- 
spond to 20 per cent, of haemoglobin. 

In some diseases, such as pernicious anaemia, the haemo- 
globin per cent, is higher than the red cell per cent, because 
of the increased size of cells. To illustrate : in a given case 
the haemoglobin is 30 per cent. ; the red count 1,000,000, or 
20 per cent. ; the color-index is f . 

In chlorosis the color-index is low. 

Estimation of the Specific Gravity.— An indirect method 
of calculating the per cent, of haemoglobin is by estimating 



42 CLINICAL EXAMINATION OF THE BLOOD. 

the specific gravity of the blood. The best method is that of 
Harnmerschlag. Such a mixture of chloroform and benzol 
is made in a urinometer cylinder as will give a specific gravity 
of 1059 (normal specific gravity of the blood), unless dealing 
with a very anaemic blood, when time will be saved by mak- 
ing a lighter mixture. The finger is freely punctured, a large 
drop of the blood drawn up into a capillary tube (a medicine- 
dropper will answer) and quickly deposited in the liquid ; or 
the blood may be squeezed from the finger and allowed to 
drop into the cylinder. It should float in the middle of the 
liquid. If it sinks, its specific gravity is greater than that 
of the mixture ; if it rises, it is lighter. In case it sinks, 
add sufficient chloroform (which is heavier than water) to 
cause it to remain floating in the middle of the liquid. Place 
the urinometer in the mixture, note the specific gravity, and 
compare with the appended scale. 



(» Hemoglobin. 


Ky Hemoglobin. 


1030.0 = 20 per cent. 


1049.0= 60 per cent. 


1035.0 = 30 


a 


1051.0= 65 " 


1038.0 = 35 


<; 


1052.0= 70 " 


1041.0 = 40 


u 


1053.5= 75 " 


1042.5 = 45 


u 


1056.0= 80 " 


1045.5 = 50 


it 


1057.5= 90 " 


1048.0 = 55 


u 


1059.0 = 100 " 



The urinometer should be perfectly dry. It is w r ell to 
have several drops of blood in the glass ; add the chloroform 
and benzol a few drops at a time, and stir thoroughly with a 
glass rod after each addition. 

The mixture of chloroform and benzol may be filtered and 
kept in a special bottle, and used over and over again. 

Counting the Red Corpuscles. — The finger is cleansed 
and punctured. As soon as the blood is flowing freely, a red- 
blood pipette is brought into contact with the drop, suction 
made, and the blood drawn up to the mark 0.5. In the case 
of an extremely anaemic patient draw it up to the mark 1. 

Considerable experience is required to do this with exact- 
ness. If the mark is slightly overreached, touch the point of 



PRELIMINARY REMARKS. 



43 



the pipette against the towel till the column is brought back 

to the 0.5 mark. 

Fig. 10. 












0.100 mm. 
Ttjo mm. 


Yd 1 

I Ol 











Thoma-Zeiss blood-counting apparatus. 

(Beginners will find it useful to practise drawing up a 
colored fluid like Toisson's before experimenting with blood, 







Fig. 


11. 








o CO 


°, .*o 


• 

* 9 




o » 9 




" '.V 


. o » 


o° °, ° 


« o . ° 




* ° 


' t 


< * * * 


^^« » 


o° ." a * 


O * ° 


e .° 




»" ' 


■ o*o 


• * , 

• • e 




9 
O • 
o O 




o ' 
. e o 


< 


o 4 « 


* * o ° 

e • 6 


'o j » 


e • 

» « 


:•: 


° oC o 

o • 

e 


o* • 




• . B 


• • o 


« e 


o 


c • 


o ° 

O 

• o 


« J 




• 

••• °« 


a 
• • O 

°« 


• • 


» 




• 

• 

a 


• 
^ 9 


' 0° 

•A 


*. c o ° t 


" t O 3 


•» 0* 


e .° n 


Co* 

• a 


1* . 


' o • 




« » o e 


;•• 


oV- 


•oV 


O 


» 9 


9 o o a 


4 o ° 


4 O 

• • 


e ■ ° 


: v: 


''?. 


» • 



Appearance of blood in the Thoma-Zeiss cells. 

which is likely to coagulate in the pipette and give much 
trouble.) 

When the blood is drawn to the proper mark, and that on 



44 CLINICAL EXAMINATION OF THE BLOOD. 

the outside of the tube wiped oft* (being careful not to touch 
the point), the pipette is immediately plunged into the dilut- 
ing solution and suction made as soon as it is below the sur- 
face. This is drawn up until the mark 101 is reached. The 
pipette, held in the horizontal position, is tapped rapidly 
with the fingers, in order to mix thoroughly the blood. Next 
blow out the diluting fluid and place a medium-sized drop of 
the diluted blood upon the small glass cylinder in the count- 
ing-chamber. 

Considerable practice is required to obtain a drop of the 
proper size. In securing the correct dilution of the blood, 
the rubber tubing attached to the pipette should be long 
enough to allow the eyes to be brought on a level with the 
0.5 mark, otherwise too much blood will be drawn up. The 
pipette must be thoroughly clean, dry and free from bubbles. 
The next step is the careful adjustment of the cover-slip over 
the drop of diluted blood. The drop should now nearly 
cover the central glass slide ; there should be no air bubbles 
in it ; it should not overrun the gutter. If the slide be held 
up to the light on a level with the eyes, a play of colored 
rainbow rings (Newton's) may be seen. This indicates that 
the technique has been correct. A few minutes should elapse 
before counting to allow the corpuscles to settle. 

The counting-chamber is exactly ^ of a millimetre deep. 
The ruled square used for counting reds is a square milli- 
metre divided into 400 small squares, so that each small 
square is ±\^ square millimetre. Use the low dry lens, with 
most of the light shut off. 

It is well to adopt the rule of beginning with the lower 
right square, and counting upward. Every fifth square above 
and to the left is subdivided by an extra line to facilitate the 
counting. The corpuscles lying on the upper and left lines 
are counted ; those on the lower and right are not. Continue 
this upward course till five squares are counted, then take the 
next square to the left and go down 5, then the next to the 
left and go up again 5 squares, and so on till the number of 
corpuscles in 200 small squares is counted. This sum is 
divided by 200, thus giving the number in each small square. 



PRELIMINARY REMARKS. 45 

To calculate the number of corpuscles per cubic millimetre, 
multiply by 100, because the blood has been diluted 100 
times; then by 400, because each small square is -^-§ of a 
square millimetre; then by 10, as the square millimetre is 
only -^ of a millimetre deep. This gives the number of 
corpuscles in a cubic millimetre. In short with a dilution 
of 1 :100, the number of corpuscles in each small square is 
multiplied by 400,000. If the dilution has been 1 : 200, mul- 
tiply by 800,000. 

Counting the White Corpuscles. — A white-blood counter, 
with which it is possible to make dilutions of 1 : 20 and 
1 : 40, is used. The diluting solution is 0.3 per cent, of 
glacial acetic acid, which destroys the red corpuscles. 

A free puncture must be made, since a much larger drop is 
required than in making the red count. Because of the large 
bore of the pipette great care should be taken in sucking up 
the blood, and later in securing the proper-sized drop for 
counting. In depositing this drop on the counting-chamber, 
the pipette must be held in an almost horizontal position. 
The diluted blood flows out without blowing. The diaphragm 
of the microscope is adjusted so as to shut off considerable 
light, in order to make prominent the white corpuscles. 
They appear as small granular balls. 

Several methods of calculating the number of leukocytes 
have been devised. 

1. Turck's modification of the Thoma-Zeiss blood-counter 1 
(Fig. 12) is intended for the accurate and rapid counting of 
leukocytes. It differs from the Thoma-Zeiss counting-cham- 
ber in having 9 square millimetres accurately ruled off, instead 
of 1. The central square millimetre is divided into 400 small 
squares, as in the original, and is used for counting red cells. 
By means of this counting-chamber the leukocytes in 9 square 
millimetres may be counted with each drop of the diluted 
blood, thus rendering it unnecessary to count more than 2 or 
3 drops. The presence of so many lines makes it much easier 
to count the cells and less likely that they will be counted 
more than once or not at all. 

1 Wiener klinische Wochenschrift, July 10, 1902, p. 717. 



46 



CLINICAL EXAMINATION OF THE BLOOD. 



Example. — In a space of 9 square millimetres 270 leuko- 
cytes were counted, an average of 30 to each square milli- 
metre. Multiply 30 by 10, to give the number in a cubic 
millimetre— that is, 300. Next multiply 300 by 20, the 
number of times the blood was diluted, giving a total of 6000 
per cubic millimetre. 

2. By Use of Thoma-Zeiss Counting-chamber and a Specially 
Calculated Leukocyte Table. — This rapid method is employed 
almost entirely in Dock's clinic. The tube of the microscope 
is drawn out until the periphery of the microscopical field 

Fig. 12. 




Turck. 



exactly cuts the corners of the large square millimetre. With 
some microscopes this can not be done. A piece of dark 
cardboard, out of which has been cut a circle of the correct 
size to give the above field, should be placed in the eye-piece 
of such instruments. The slide is moved about and all cor- 
puscles in several of such fields are counted. Two or three 
drops should be treated in this way. The sum of the corpus- 
cles is divided by the number of fields, giving the average 
for a field. This number is found on the table and the num- 
ber of leukocytes is read off. This method, known as the 
calibration method, is sufficiently accurate for all practical 
purposes. Upon it is based a still shorter method, devised by 
F. T. Wright, which is fully described in another paragraph. 



PRELIMINARY REMARKS. 47 

Leukocyte Table (dilution 1 : lfi\ 

1— 254 41—10,441 81—20,626 

2— 509 42—10,695 82—20,881 

3— 763 43—10,950 83—21,136 

4— 1,018 44—11,204 84—21,390 

5— 1,274 45—11,457 85—21,645 

6— 1,528 46—11,714 86—21,900 

7— 1,782 47—11,938 87—22,154 

8— 2,037 48—12,223 88—22,409 

9— 2,292 49—12,478 89—22,664 

10— 2,546 50—12,732 90—22,928 

11— 2,801 51—12,987 91—23,173 

12— 3,056 52—13,243 92—23,426 

13— 3,310 53—13,496 93—23,682 

14— 3,565 54—13,751 94—23,937 

15— 3,820 55—14,006 95—24,191 

16— 4,074 56—14,260 96—24,446 

17— 4,329 57—14,575 97—24,701 

18— 4,583 58—14,770 98—24,955 

19— 4,838 59—15,024 99—25,210 

20— 5,093 60—15,278 100—25,464 

21— 5,348 61—15,533 101—25,719 

22— 5,602 62—15,788 102—25,974 

23— 5,857 63—16,043 103—26,228 

24— 6,112 64—16,297 104—26,483 

25— 6,366 65—16,552 105—26,737 

26— 6,621 66—16,807 106—26,992 

27— 6,875 67—17,061 107—27,247 

28— 7,130 68—17,316 108—27,501 

29— 7,385 69—17,571 109—27,756 

30— 7,639 70—17,825 110—28,011 

31— 7,894 71—18,080 • 111—28,266 

32— 8,148 72—18,335 112—28,520 

33— 8,403 73—18,589 113—28,775 

34— 8,657 74_18,844 114—29,030 

35— 8,912 75—19,099 115—29.284 

36— 9,167 76—19,353 116—29,539 

37— 9,421 77—19,608 117—29,793 

38— 9,676 78—19,868 118—30,046 

39— 9,931 79—20,117 119—30,302 
40—10,186 80—20,372 120—30,557 

Short Method of Calculating Leukocytes. — The follow- 
ing excellent method, suggested by F. J. Wright, is used in 
the Calumet and Hecla Hospital : 

Dilute blood 1 : 40, count 5 fields (the periphery of the 
field should cut the corner of the large square), divide their 



48 STUDY OF THE STAINED SPREAD. 

sum by 2, and add 2 ciphers. This gives the number of leu- 
kocytes with sufficient accuracy for practical purposes. 

Example : 150 leukocytes are counted in 5 fields. 150^- 2 
= 75. Add 2 ciphers, and 7500 is obtained, the approxi- 
mate number of leukocytes per cubic millimetre. 

When leukocytes are very numerous, as in some cases of 
leukaemia, it is best to employ the red counter and make dilu- 
tions of 1 : 100. 

Durham's modified hsematocytometer combines the use of 
the Thoma-Zeiss counting-chamber with a self-measuring 
pipette, for obtaining the. blood, pipettes for measuring the 
diluting fluid, and small test-tubes for making the dilution, 
giving dilutions of 1 : 200, 1 : 100, and 1 : 50. It has many 
advantages for the unskilled person, and is much more easily 
cleaned than the Thoma-Zeiss pipettes. 

For a full description of this method see Cabot. 

QUESTIONS. 

What are the constituents of normal blood ? 

Mention the various factors which alter the quality of the blood ? 

What procedures are included in the clinical examination of the blood? 

Describe the fresh drop examination. 

Describe the various methods of estimating the haemoglobin. 

What is meant by the color -index? 

Describe Hammerschlag's method of estimating the specific gravity. 

Describe the best method of counting the red blood-corpuscles. 

Mention the various methods of counting the white blood-corpuscles. 



CHAPTER IV. 
STUDY OF THE STAINED SPREAD. 

MAKING SPREADS. 

(1) Cover-glass Method. — The cover-glasses should be 
thoroughly cleaned and well polished. Place them upon a 
blood-board covered with filter-paper. Clean the finger, 
prick it, wipe off the first drop of blood, pick up the cover- 



MAKING SPUE ADS. 



49 



glass with forceps, touch its centre to the exuding drop before 
it becomes too large. Place upon another cover-glass in such 



Fig. 13. 



Fig. 14. 




Proper method of holding a cover-glass. (Cabot.) 



Illustrating the position of 
cover-glass during the spread- 
ing of blood-films. (Cabot.) 



a way that all corners project, The blood should spread in a 
thin fim. Pick up with forceps and slide the cover-glasses 



Fig. 15. 




apart along the same plane, the lower cover being held by 
the thumb and forefinger of the left hand, the upper by the 
4— c. D. 



50 STUDY OF THE STAINED SPREAD. 

forceps or the thumb and forefinger of the right hand. The 
essentials for a good spread are: first, quickness; second, 
clean cover-glasses ; third, drop of proper size. 

If the cleaned cover-slips are passed through the flame just 
before spreading, better films will result. 

(2) Slide Method. — This method has become widely 
adopted. For the inexperienced it is the better method. It 
is very easy of application, and one is certain to find some 
part of the large field which is well spread. The polished 
edge of a slide held between thumb and fingers is touched to a 
medium-sized fresh drop of blood and pressed against another 
slide near its end. As soon as the blood spreads across the 
edge of the smearer, draw it gently and evenly along the 
lower slide till the drop is exhausted. The blood should be 
pushed before the smearer (Fig. 15). A cigarette paper 
may be used as a spreader in place of the upper slide. 

To secure the best spreads, they should be immediately 
dried over a gas or alcohol flame, but for the majority of 
clinical work air-dried specimens are sufficiently good. 

FIXING THE FILMS. 

Depending on the stain to be used, films may be fixed or 
remain simply air-dried. The selection of the stain decides 
whether the film should be fixed by heat or one of several 
fluids or gases. 

If the Ehrlich triacid stain is to be used, fixation by heat 
is essential. If eosin and hsematoxylon or eosin and methyl- 
ene-blue are to be used, fix in a solution of equal parts of 
absolute alcohol and ether for from five to thirtv minutes, or 
in the same solution (30 c.c. each) to which 5 drops of a satu- 
rated alcoholic solution of corrosive sublimate are added (five 
minutes). Absolute alcohol alone, or 2 per cent, chromic 
acid, or exposure to the vapor of 45 per cent, formalde- 
hyde may also be used. If in a hurry, the air-dried spread 
may be stained with eosin and hsematoxylon, with fair re- 
sults. 

Fixation by Heat. — A small dry heat sterilizer with ther- 



STAINING THE SPREAD. 51 

mometer registering 200° C. is heated by a Bunsen burner or 
alcohol lamp. 

The blood-spreads are placed film downward upon the shelf 
of this sterilizer, and heat applied to 115° to 150° C. The 
degree of heat necessary must be determined for each steril- 
izer by heating a number of films at different temperatures 
and staining with triacid. . 

The film showing red corpuscles stained a bright yellow 
indicates the correct temperature for that oven. As soon as 
the heat reaches the proper temperature it should be turned 
off. 

For routine work, fixation in the free flame of the Bunsen 
burner or alcohol lamp is very satisfactory. The cover-glass, 
specimen side up, is grasped with forceps and passed slowly 
through the flame, about twenty times, until it is too hot for 
the hand to bear. This means a temperature between 110° 
and 150° C. If overheated, the film changes color. Most 
mistakes are made on the side of underheating, with incom- 
plete fixation and subsequent vacuolization of the cells. The 
film may also be fixed by holding it above the free flame, at 
such a distance that the heat is just bearable by the hand. 

STAINING THE SPREAD. 

Probably what will prove to be the best all-round stain 
in blood-work is one which has been devised by Wright, 
of Harvard. The somewhat troublesome fixing of films is 
done away with, as this stain works best with fresh unfixed 
spreads. Its application is extremely simple, and its results 
show that it is more widely applicable than any stain ever 
devised. It is the best malarial stain known. For the 
method of making the stain, see Chapter I. 

Staining of Blood-films. — 1. Make films of the blood, 
spread thinly, and allow them to dry in the air. 

2. Cover the preparation with the alcoholic solution of the 
dye for one minute. 

3. Add water to the alcoholic solution of the dye on the 
preparation, drop by drop, until the mixture becomes semi- 



52 STUDY OF THE STAINED SPREAD. 

translucent and a yellowish metallic scum forms on the surface. 
Allow this mixture to remain on the preparation for two or 
three minutes. 

4. Wash in water (preferably distilled) until the film has a 
yellowish or pinkish tint in its thinner or better spread por- 
tions. 

5. Dry between filter-paper anc] mount in balsam. 

Dried blood-films may be kept for some weeks without im- 
pairment of their staining properties ; but if kept too long, 
will not give good results. 

MICROSCOPICAL APPEARANCES IN BLOOD-FILMS 
STAINED BY THE METHOD OF WRIGHT. 

Red cells are orange or pink in color ; polychromatophilia 
and punctate basophilia (the granular degeneration of Grawitz) 
are well brought out. The nucleated red cells have a deep- 
blue nuclei, and the cytoplasm is usually of a bluish tint. 

Lymphocytes have dark purplish-blue nuclei, and robin's 
egg blue cytoplasm in which a few dark-blue or purplish 
granules are sometimes present, 

Polynuclear neutrophilic leukocytes have dark-blue or 
dark -lilac colored nucleus, and the granules are usually of a 
reddish-lilac color. 

Eosinophilic leukocytes have blue or dark-lilac colored 
nuclei. The granules have the color of eosin, while the 
cytoplasm in which they are imbedded has a blue color. 

Large mononuclear leukocytes appear in at least two 
forms. Each form has a blue or dark-lilac colored nucleus. 
The cytoplasm of one form is pale blue, and of the other form 
is blue with dark-lilac or deep-purple colored granules, which 
are usually not so numerous as are the granules in the poly- 
nuclear leukocytes. 

Mast-cells appear as cells of about the size of polynuclear 
leukocytes with purplish or dark-blue stained, irregular- 
shaped nuclei, and cytoplasm, sometimes bluish, in which 
numerous coarse spherical granules of variable size are im- 
bedded. These granules are of dark-blue or of a dark-purple 
color, and may appear almost black. 



MICROSCOPICAL APPEARANCES IN BLOOD-FILMS, 53 

Myelocytes have dark-blue or dark-lilac colored nuclei, 
and blue cytoplasm in which numerous dark-lilac or reddish- 
lilac colored granules are imbedded. 

The blood-plates are deeply stained, and are a promi- 
nent feature of nearly every blood preparation. They appear 
as blue or purplish rounded or oval bodies, usually of a 
diameter of a third to a half of that of a red blood-corpuscle. 
Sometimes they appear in groups or masses, and at first sight 
may be regarded as precipitates. In many instances they 
have the appearance of being within a red corpuscle and 
surrounded by an unstained zone of its cytoplasm. 

Malarial Parasites. — The body of a malarial parasite stains 
blue, while the color of the chromatin varies from a lilac 
color through varying shades of red to almost black. In the 
young forms of the tertian and sestivo-autumnal parasite the 
chromatin appears as a spherical very dark-red body, while 
in the older forms of the tertian parasite it has a more lilac 
or purplish-red color, and may appear in the form of a reticu- 
lum. In the intermediate forms the color of the chromatin 
may present variations between these extremes. The inex- 
perienced observer may mistake the blood-plates apparently 
situated within the red blood-cells for malarial parasites. This 
will not occur if he bear in mind that the young parasite of 
all the three kinds should present by this method a dark-red 
spherical nucleus, and a cytoplasm which is usually in the 
form of a definite ring. This method of staining will bring 
out dark-red staining granules in the red corpuscles harboring 
malarial parasites provided the stain after the water has been 
added to it is allowed to remain on the preparation for at 
least five minutes, and not to decolorize for so long a time 
as with the ordinary stain. 

Following the success of the Romanowsky stain in demon- 
strating the chromatin material of parasites, the methylene- 
blue-eosin stains have acquired a deserved prominence. 
Among these may be mentioned Jenner's, Rosin's, Irish- 
man's, and Wright's. Jenner and Wright use pure methyl 
alcohol as solvents of their stains, while Rosin and Leish- 
man employ pure ethyl alcohol as a solvent. Wright's stain 



54 STUDY OF THE STAINED SPREAD. 

may be selected from this list as probably the best, though 
the others are excellent. 

As a differential stain for leukocytes, Jenner's stain has 
proved uncertain in staining neutrophile granules. The 
staining of the chromatin in the nuclei of malarial parasites 
is seldom accomplished satisfactorily. With Wright's stain, 
on the other hand, the chromatin is stained as beautifully as 
it is with the Nocht Romanowsky method. It must be 
remembered that those mixtures of methylene-blue and eosin 
which stain the chromatin material of the cell in varying 
shades of violet depend for this characteristic not upon 
methylene-blue, but upon its oxidation product, the methyl- 
ene-azure of Bernthsen ; and that the solutions in alcohol 
(ethyl or methyl) of neutral stain — Reuter, Leishman, Wright 
— which has been prepared from polychrome (alkaline) 
methylene-blue probably contain a large amount of methyl- 
ene-azure eosin in proportion to the methylene-blue-eosin. 

The Ehrlich tricolor mixture has for vears been the most 

* 

popular stain with many workers. The objections to it are 
(1) that it is difficult to prepare a good stain, and (2) that the 
films must be fixed by heat. (The first objection may be 
overcome by sending to Walter Dodd, apothecary to the 
Massachusetts General Hospital, who furnishes an absolutely 
reliable stain for 65 cents a small bottle.) For method of 
making the stain, see Chapter I. 

A drop of the stain is spread over the film, allowed to 
remain five minutes or more, and washed off with water. 
(It is impossible to overstain.) The specimen should look 
orange-yellow ; if it is brown or red, it is underheated — not 
overstained. If overheated, everything is blurred and dim 
under the microscope. Hewes improves the definition of the 
nuclei by pouring upon the film for a second or two a satu- 
rated aqueous solution of methylene-blue, after the triple 
stain has been washed off with water. This also brings out 
the malarial parasite. 

Appearance of Films Stained with the Ehrlich Tri- 
color Mixture. — Blood-films, properly heated and stained 
with the above mixture, when normal, react as follows ; 



MICROSCOPICAL APPEARANCES IN BLOOD-FILMS, 55 

Red Cells. — The haemoglobin of the red cells stains with 
the orange-G, and if the spread is properly heated takes a 
brilliant yellow or orange tint. If overheated, they have a 
feebly stained, washed-out look ; while if underheated, they 
are brown or gray. The degree of pallor in the centres cor- 
responds to the amount of haemoglobin in the corpuscle. One 
who is accustomed to spreading blood in a uniform way can 
judge approximately of the number of red cells. 

The fibrin and blood-plates are not seen. The plasma does 
not stain in normal cases. A certain amount of debris is 
often present, usually stained pink. 

White Cells. — The chief value of the triple stain is the 
fact that it enables one to recognize the important varieties of 
leukocytes, by differentially staining them. 

In normal blood the following varieties of white cells are 
found : 

1. Small Lymphocytes. — These are made up chiefly of a 
round blue nucleus about the size of a red cell, surrounded by 
a thin coating of protoplasm. This is faintly stained or 
invisible with Ehrlich's triple stain, but takes on a dark 
patchy blue when Hewes' after-stain is used. With this after- 
stain the nucleus becomes an intense indigo color. 

2. Large Lymphocytes or Large Mononuclear Cells. — These 
are simply larger and paler, and the nucleus occupies rela- 
tively less of the cell than in the small lymphocytes and 
stains less readily. In some bloods there are no interme- 
diate forms. Lymphocytes are either " small " (5 to 10 /z in 
diameter) or "large" (13 to 15// in diameter). 

In other cases we find every intermediate size, both of 
nuclei and of the cells as a whole. It is not rare to find the 
so-called mononuclear cells, whose nucleus has a deep cut in 
one side, or has divided into two parts. Cabot groups the 
large mononuclear leukocyte with the large lymphocyte. 

3. Transitional forms resemble the large lymphocytes, 
except that they have an indentation in their nucleus, either 
narrow or wide. Both the nucleus and protoplasm are pale. 

The cells known as polynuclear or poly(morpho)nuclear 
neutrophiles constitute the vast majority of those found in 



56 STUDY OF THE STAINED SPREAD. 

ordinary pus. The nucleus stains deeply. It is very irregu- 
lar in shape, being compared to the letters Z, S, E; at times 
it seems to have several distinct nuclei, but this is due to the 
fact that the nucleus dips dowfi deep and then comes again to 
the surface. There are usually underground connections. 
The body of the cell is filled with small neutrophilic granules. 
They are much smaller than the large round eosinophile 
granules. They stain violet or purple, at times pink. The 
younger the cell the more violet the color. They are called 
neutrophile because they do not stain with acid stains like 
eosin, or with basic stains like methylene-blue. It requires a 
high power to see these granules ; with a low power they look 
like a diffuse stain. They rarely occur except in cells whose 
nucleus has reached the polymorphous stage. 

The eosinophiles, or coarse granular oxyphile cells, have 
polymorphous nuclei and granules ; but the nucleus is paler 
and more loosely connected to the granules. The granules 
are spherical or oval, of nearly uniform size, and much larger 
than the neutrophile. They have a strong affinity for acid 
coloring-matter (eosin and fuchsin). They are of a copper 
or burnt sienna color. The eosinophiles are the most actively 
amoeboid of all the corpuscles, and it may be for this reason 
that the different parts of the cell seem so loosely strung 
together. In cover-glass specimens we more often find a 
separation of the nucleus and the granules than in any other 
cells. 

The basophilic "mast-cell " is a constituent of normal 
blood ; 0.5 per cent, is the maximum number in health. The 
triple stain does not bring it out well. 

Eosin and Haemotoxylon. — This stain is especially useful 
in studying the blood of pernicious and other severe anae- 
mias, since it brings out the finer structure of the nuclei. 
The spread should be fixed in ether and alcohol. Cover the 
spread with eosin for about one-half minute, wash in water, 
then examine under low-power lens to learn whether the cor- 
puscles have the proper tint. If too deeply stained, wash 
still further. Cover with filtered haematoxylon for about one 
minute, wash, dry between filter-paper, and mount. The 



MICROSCOPICAL APPEARANCES IN BLOOD-FILMS. 57 

red cells should be stained a light pink ; the nuclei of white 
cells and nucleated red cells a dark purple. The only gran- 
ules stained are the eosinophiles. The malarial parasite is 
not stained by this method. 

Eosin and Methylene-blue. — Method. — Fixation, alcohol, or 
alcohol and ether. Cover the smear with eosin for one-half to 
one minute ; wash in water. From the appearance of the film 
one soon learns whether the preparation is overstained or under- 
stained. To be certain, examine under a low-power lens. 
If overstained, wash longer in water ; if understained, add 
more eosin. Next cover stain with methvlene-blue for one 
minute, wash quickly, and dry. 

This method may be used for ordinary blood- work. Its 
chief advantages are that it stains the basophilic granules and 
malarial parasites. It does not bring out the neutrophile 
granules or nuclei clearly. One must guard against over- 
staining with eosin, otherwise the methylene-blue does not 
act well. 

Demonstration of Mast-cells with Ehrlich's Dahlia Solution. 
— The large basophilic granules of these cells retain basic dyes 
with greater tenacity than most other basophilic granules. 

Stain several hours, wash in water, decolorize in alcohol, 
till the nuclei fade, and again wash in water. The nuclei of 
leukocytes are then very pale blue, and the mast-cell granules 
very dark blue or black. 

Demonstration of Glycogenic Granules tvith Iodophilia 
Mixture. — For the preparation of this mixture and its appli- 
cation, see Chapter VII. (Diseases in which Diagnosis De- 
pends on Blood Examination). 

Origin of the Different Varieties of Physiologic Leukocytes. 

I. The myelogenous group. (a) Poly(morpho)nuclear 

(From the bone-marrow.) (b) Eosinophiles. 

(c) Mast-cells. 

(d) Large mononuclear cells. 

II. The lymphogenous group. Lymphocytes of all sizes, 

(From adenoid tissue.) 



58 STUDY OF THE STAINED SPREAD. 

Normal Per cent of Each Variety. 

, v j Small lymphocytes, 20-30 per cent, 

w \ Large " 4-8 " " 



a 



(b) Polymorphonuclear neutropbiles, 62-70 

(c) Eosinophils, |—4 " 

(d) "Mast-cells," ^-1 " 

In infancy the percentage of lymphocytes is much larger 
(40 to 60), and the polymorphonuclear only 18 to 40 per 
cent. 

Poorly nourished, debilitated people show an excess of 
lymphocytes and a diminution in the polynuclear cells. The 
opposite condition prevails in vigorous health. 



Pathologic Leukocytes. 

1. Myelocyte. — This is a mononuclear neutrophile, and has 
many points of resemblance to the polynuclear neutrophile ; 
it is the same cell in an early stage of growth. 

This cell makes up the larger portion of the leukocytes of 
the marrow, and differs from any variety found in normal 
blood. 

It is found in the blood in various diseased conditions, and 
resembles very closely the large lymphocytes, differing only 
in possessing neutrophile granules. It differs from the poly- 
nuclear neutrophile in the shape of its nucleus, but the gran- 
ules in both are alike. The nucleus is usually spherical or 
egg-shaped, and is in close contact with the cell-wall for a 
comparatively large portion of its extent. 

The average diameter of 100 myelocytes, 15.75 /u. 

100 polynuclear leukocytes, 13.50 ft. 
100 large lymphocytes, 13.00 fi. 
100 eosinophils, 12.00 ft. 

100 small lymphocytes, 10.00 //. 
100 red corpuscles normal, 7.50 ft % 



(C 


u 


cc 


u 


cc 


cc 


it 


a 


cc 


a 


cc 


cc 


<( 


cc 


u 



MICROSCOPICAL APPEARANCES IN BLOOD-FILMS. 59 

Eosinophilic Myelocytes. — Myelocytes having eosinophile 
instead of neutrophile granules occasionally occur. 

The eosinophile granules do not all take the same stain ; 
some are darker than others. 

Atypical cells : 

I. Degenerated or Moribund Leukocytes. — (1) A homogene- 
ously stained mass looking like a washed-out, structureless 
nucleus that has lost its protoplasm and become ragged at the 
edges (karyolysis). 

(2) The same intensely stained. 

(3) Vacuolization of the nucleus or of the protoplasm. 

In the granular leukocytes the granules are scattered about 
the field, and the nucleus is pale, structureless, and deformed. 

II. Transitional Neutrophile. — Between marrow-cell and 
polymorphonuclear. 

Ill TiircWs "Stimulation Forms." — Described by Weil 
as nongranular myelocytes. They are associated with stimu- 
lation of the bone-marrow, grave anaemia, and all conditions 
in which there is a leukocytosis. 

Differential Counting. — For satisfactory work a mechanical 
stage is essential. At least 500 leukocytes should be counted 
and checked off opposite their names according to the list 
given on pages 58 and 61. Begin in the lower right-hand corner 
of the film, and, by turning the thumb-screw, work upward, 
covering the film carefully, checking off the leukocytes as they 
appear and are recognized. When the top of the film is 
reached, move one field to the left and w T ork downward ; con- 
tinue till a sufficient number of corpuscles are counted. At 
the same time watch for alterations in the red corpuscles, as, 
for example, nucleated reds. 

QUESTIONS. 

What are the various methods of making blood-spreads ? 

Mention several methods of fixing blood-spreads. 

What advantage has the methylene-blue-eosin stains over the older stains? 

Mention the points of distinction between the various kinds of leukocytes. 

What is the normal per cent, of each variety of leukocytes? 

Of what importance is differential counting? 



60 PATHOLOGICAL CONDITIONS OF THE BLOOD. 

CHAPTER V. 

PATHOLOGICAL CONDITIONS OF THE BLOOD. 

Classification. — The following deviations from the normal 
may be observed : 

1. Diminution in haemoglobin. 

2. Diminution in the red count. 

3. Increase or diminution in the white count. 

4. Alteration in color-index. 

5. Diminution in the specific gravity. 

6. Alterations in the size and shape of the red cells — L e. } 
jwikilocytosis. 

7. Alterations in the staining properties of the red cells — 
i. e. 9 polychromatophilia. 

8. Presence of abnormal forms of red cells. 

9. Presence of abnormal forms of white cells. 

10. Alteration in the normal ratio of different varieties of 
white cells. 

11. Presence of parasites in the blood. 

Various combinations of these changes are shown in many 
of the diseases which are discussed in another chapter. 

Poikilocytosis. — By this term is meant unusual alterations 
in the size and shape of the red corpuscles ; some are very 
large, almost twice the size of the average red cell ; some 
very small, being only about half the size. 

In shape these cells resemble dumb-bells, Indian clubs, 
beets, etc. All sorts of irregular, ragged cells are to be 
found. 

Polychromatophilia. — With special stains certain of the 
red cells take on a darker color than the remainder of the 
cells, the tint varying with the stain used. This is due to a 
degenerative process, which changes the staining properties 
of the cells, so that they take up several colors. 

Endoglobular Degeneration. — This consists of the pres- 
ence of clear, unstained spaces of various shapes within the 
corpuscles. In the fresh specimen these spaces are clear and 
change their shape continually. 



ABNORMAL FORMS OF RED CELLS. 61 

Granular Degeneration of Red Cells (Grawitz) or Punc- 
tate Basophilia of Red Cells. — In certain diseases — malaria, 
lead-poisoning, severe anaemia, etc. — red cells often show 
small bluish granules. These are well brought out by 
Wright's stain. The weight of evidence suggests that they 
are remnants of nuclei. Red corpuscles harboring malarial 
parasites often show these granules. 

Abnormal Forms of Red Cells. 

Nonnucleated : (a) microcyte — a very small red cell ; (b) 
megalocyte — a very large red cell. 

Nucleated : (a) microblast ; (b) normoblast ; (c) megalo- 
blast ; (rf) atypical forms of nucleated red cells — called metro- 
cytes by some authors. 

Microblast. — A very small red cell, made up chiefly of a 
nucleus similar to that of the normoblast. There is a narrow 
rim of protoplasm around the nucleus. It has perhaps the 
same significance as the megaloblast. 

Normoblast. — It differs from the normal red cell in having 
a deeply stained, round nucleus, about one-half the diameter 
of the whole cell, situated somewhat excentrically. At times 
the nucleus is so situated that it looks as if the cell were 
extruding it. 

Megaloblast. — This does not occur anywhere in the healthy 
adult body. It is found in the early foetal marrow, and in 
the marrow and blood of grave forms of anaemia. Accord- 
ing to Ehrlich, the megaloblast indicates the presence of the 
foetal types of blood formation. It is a grave prognostic 
sign, and when present in excess of normoblasts it indicates a 
pernicious form of anaemia. The only exception which clini- 
cians have found to this view is the fact that the anaemias due 
to intestinal parasites, and showing a pernicious blood condi- 
tion, may recover under appropriate treatment. 

Megaloblasts may be found in milder forms of anaemia, but 
the normoblast is the prevailing type. The typical megalo- 
blast is a very large red cell, at times twice as large as the 
average (11 to 20 fi in diameter). Its protoplasm frequently 
shows marks of degeneration (polychromatophilia). The 
nucleus is very large and pale, filling most of the cell, thus 



62 PATHOLOGICAL CONDITIONS OF THE BLOOD. 

contrasting greatly with the normoblast. It does not stain 
evenly, but has a mesh-like appearance, with darker and 
lighter areas. The entire cell reacts differently with Wright's, 
Ehrlich's triple, and the eosin-haematoxylon stains (see de- 
scription of these stains). The cell may be circular, but is 
more often oval or somewhat irregular. 

Metrocytes. — One frequently iinds in anaemic blood nucle- 
ated red cells, w 7 hich can not be classed as typical normoblasts 
or megaloblasts. The whole cell is too small, or the nucleus 
is lacking in certain characteristics. These are classed as 
atypical forms of nucleated red cells, or metrocytes. 

The real criterion of the two varieties, according to Pappen- 
heim, is the structure of the nuclear network (pale nuclei with 
delicate chromatin network is indicative of a young megalo- 
blast). 

Most megaloblasts in the blood are young, while most nor- 
moblasts are old, as shown by their small, dark, coarse-skeined 
nuclei. For ordinary work Cabot gives the following rule : 
Any nucleated red cell more than 10 /i in diameter should 
be classed as a megaloblast, whatever the appearance of its 
nucleus ; and any nucleated red cell less than 10 jjl in diame- 
ter is probably a normoblast, whatever the appearance of its 
nucleus. 

Karyokinesis. — Red cells with dividing nuclei are fre- 
quently found in severe anaemias — especially in leukaemia. 

Degeneration of Leukocytes. — Glycogenic degeneration 
of leukocytes or iodophilia is demonstrated by means of a 
stain made up of iodine in mucilage of acacia (see Chapter I.). 
The mixture is painted on a slide, and the unfixed cover-glass 
preparation pressed down upon it. When the reaction is 
present, the protoplasm of the leukocytes stains brown, slight 
or intense, with deeply stained flakes or granules. 

Acute Degeneration of Leukocytes. — Very little is known 
about this, but Ewing recognizes the following evidences of 
acute degeneration : 

(a) Increased acidophile staining tendency in the neutro- 
phile granules. 

(b) Diminution in the number of neutrophile granules. 



ABNORMAL FORMS OF RED CELLS. 63 

(c) Swelling and fragmentation of the bodies of leukocytes. 

(d) Nuclear changes; staining less deeply with basic dyes; 
irregularity of outline and lobes shrunken. 

Chronic Degeneration of Leukocytes. — This is best seen in 
myelogenous leukaemia. One finds leukocytes showing loss 
of granules, presence of vacuoles, granules of glycogen, faded 
irregular nuclei, distortion and fragmentation of cell-bodies. 

Complete subdivision of nuclei of poly nuclear cells into 6 to 
10 hyperchromatic segments is rather characteristic of leu- 
ksemic blood. 

Hydropic and fatty degeneration may be present. 

Perinuclear Basophilia of Neusser.— By this is meant the 
presence of basic staining granules about the nuclei of poly- 
nuclear and other leukocytes. It is of no clinical impor- 
tance. 

Myelocyte. — This cell is a mononuclear neutrophile, and 
has many points of resemblance to the poly nuclear neutro- 
phile — in fact, it ,is the young form of that cell. It differs 
from the large lymphocyte chiefly in being larger and having 
neutrophile granules. Its nucleus is usually spherical or egg- 
shaped, and is in close contact with the cell-wall for a com- 
paratively large portion of its circumference. Its average 
diameter is 15.75 /i. 

Eosinophilic Myelocytes. — The myelocyte rarely shows eosin- 
ophil e granules. 

The Ehrlich triacid stain alone differentiates the myelocyte 
from the large lymphocyte — by means of its granules. 

QUESTIONS. 

What is meant by poikilocytosis, polychromatophilia, endoglobular degen- 
eration, and punctate basophilia? 

Describe niicrocyte, megalocyte, microblast, normoblast, megaloblast, and 
metrocyte. 



64 THE WIDAL REACTION. 

CHAPTER VL 

THE WIDAL KEACTION. 

The "VVidal clump reaction depends on the presence of a 
substance called agglutinin in the blood of typhoid fever 
patients. It has the peculiar power of causing the typhoid 
bacilli to lose their motion and to clump. 

The blood from other diseases possesses this power, but not 
to so great a degree. 

In a limited time high dilutions of typhoid blood show 
this clumping effect, while similar dilutions of other bloods 
do not. 

This agglutinating substance is present in : 

(a) The whole blood — fluid or dried. 

(b) The plasma and serum — fluid or dried. 

(c) Blister fluid, fluid contents of normal serous cavities, 
tears, pus, breast-milk, etc. 

The whole blood or its serum — fluid or dried — is usually 
employed. 

Method of Obtaining Body Fluids. — (1) Serum. — In hos- 
pital work, where a centrifugal machine is at hand, it is best 
to use blood-serum. It is obtained as follows : A piece of 
glass tubing (small bore) is drawn out to a fine point, and 
rubber tubing attached to the large end. One or two large 
punctures are made in the finger (which has been well mas- 
saged previously), the fine point of the tube placed in the 
drop and suction made with the mouth till considerable blood 
is drawn into the pipette. This is sealed by holding the 
pointed end in the flame of a match, and immediately cen- 
trifugated. The clot should be loosened around the edge to 
allow the escape of serum. A file-mark is made at the junc- 
tion of clot and supernatant serum. With the finger over its 
top, break the tube and blow out the serum from the upper 
piece into a receptacle. If desired, dilutions without limit 
can be made with this serum as follows : One drop is placed 
in a small glass dish and 10 drops of distilled water added, 



THE WIDAL REACTION. 65 

giving a dilution of 1 : 10. With the typhoid culture, the 
cover-glass preparation is made with a drop of this dilution, 
then 10 drops more of distilled water added, giving a dilution 
of 1 : 20, the cover-glass preparation again made, then 10 
drops more added, and so on. The same pipette must be 
used for measuring the drop of serum and the water in order 
to secure accuracy. 

Whole Blood Method. — In private practice this is more 
easily carried out than the above : 

(1) An accurate dilution of 1 : 10, 1 : 20, or 1 : 40 can be 
made with a white-blood counter, using distilled water as a 
diluting fluid. 

(2) A convenient and easily applied method (especially if 
the preparation is to be sent by mail) is to allow a good- sized 
drop to dry on a cover-slip or glazed paper. If paper has 
been used, cut out the blood-drop and place in a test-tube 
containing 2 drops of water ; by agitating it the blood will 
dissolve. To obtain a dilution of 1 : 10, 8 drops of water or 
bouillon are added. 

The Culture of the Typhoid Bacillus. — A young — 
eighteen to twenty hours old — typhoid culture is required ; it 
must be actively motile. It may be grown on agar or in 
peptone bouillon, in the thermostat at 37° C. The disad- 
vantage of the bouillon is that the growth is often very 
small. Stock cultures are grown on agar at room tempera- 
ture, and are transplanted about once a month. 

Actively motile cultures show the clumping best. 

Preparation of Specimen for Microscopical Examina- 
tion. — A drop of the blood or serum diluted as desired, 
1 : 10, 1 :40, etc., is placed upon a cover-glass. By means 
of a platinum wire a bit of the typhoid culture is transferred 
from the agar tube to this drop and well stirred in order to 
separate thoroughly the bacilli. A concave slide, rung with 
vaselin, is placed upon the cover-glass, thus giving a hanging 
drop, and the preparation immediately examined under the 
microscope. A control slide should be made with distilled 
water for comparison. The preparation should now be care- 
fully examined every few minutes for loss of motility and 
5— c. D. 



66 THE WIDAL REACTION. 

signs of clumping. The length of time for the development 
of this phenomenon should be noted. 

If a bouillon culture is used, a drop of the serum or whole 
blood is added to 10 or 40 drops of the bouillon in a small 
test-tube, depending on whether a dilution of 1 : 10 or 1 : 40 
is desired. A drop of this mixture is then transferred to a 
cover-slip and a hanging drop made as before. 

Picker's Typhoid Diagnosticum furnishes the general 
practitioner, with an easily applied and trustworthy substi- 
tute for the Widal test. The fluid is manufactured by 
Merck, of Darmstadt. The entire apparatus costs $1.85. 
von Tiling carries out the test as follows : Prick the finger, 
catch a few drops of blood on a slide or a piece of filter 
paper, let it dry and later dissolve it with normal salt solu- 
tion in the proportion of 1 : 10. This diluted blood is mixed 
with the diagnostic fluid in the proportion of 1 : 5 and 1 : 10 
in two of the little test-tubes, which, therefore, contain a 
serum dilution of 1 : 50 in one glass and 1 : 100 in the second. 
Then a third glass is filled with the diagnostic fluid alone. 
The reaction is positive if after from ten to twelve hours the 
fluid in the second or third glass begins to get clear, for in 
this case the bacilli clot together and sink to the bottom. 
Sometimes the reaction proves positive in a shorter time, 
sometimes it may take twenty hours, but if no clearing of 
the fluid occurs in this time, the test is considered negative. 

Dilution and Time Limit. — Although many able men 
believe that a dilution of 1 : 10, with a time limit of half an 
hour, is sufficiently accurate, most authorities favor a high 
dilution with a special time limit ; for example, 1 : 40 with a 
limit of two hours. 

Value in Diagnosis. — From statistics we learn that about 
95 per cent, of typhoid fever patients show the Widal reac- 
tion at some time during its course. 

A negative result does not prove the absence of typhoid, 
however; only a positive result is of value. The negative 
results may sometimes be explained by the fact that the dis- 
ease, though clinically resembling typhoid fever, is due to 
infection with the paracolon or colon group. 



THE WIDAL REACTION. 



67 



Time and Appearance of Widal's Reaction. — Most 
observers give the sixth or the eighth day as about the earliest 

Fig. 16. Fig. 17. 




Pure culture. (Cabot.) 



Partial reaction. (Cabot.) 



for the reaction to make its appearance. In mild cases the 
reaction may disappear before the end of the fever, but it 



Fig. 18, 




Typical clumping. (Cabot.) 



usually persists several months, and has been known to con- 
tinue for years. 

QUESTION. 

Describe in detail the Widal reaction. 



68 LESS FREQUENTLY APPLIED PROCEDURES. 

CHAPTER VII. 

LESS FREQUENTLY APPLIED PROCEDURES. 

ESTIMATION OF ALKALINITY OF THE BLOOD. 

The alkaline reaction of the blood may be demonstrated 
by repeatedly drawing a strip of red litmus-paper, thoroughly 
moistened with a concentrated solution of common salt, 
through the blood, and rapidly washing off the corpuscles 
with the same solution. The estimation of the degree of 
alkalinity has so far proved to be a complicated, unsatisfactory 
procedure, and is of little practical importance to the clinician. 
The reader is referred to larger works on clinical diagnosis, 
where a description of von Jaksch's and Lowy's methods 
may be found. 

Engel's alkalinieter furnishes the most useful clinical 
method of estimating the alkalinity. 

INDIRECT METHODS OF ESTIMATING THE NUMBER OF 

RED CELLS. 

Oliver's Haemocytometer. — This method estimates the num- 
ber of corpuscles by means of their optical effect. It is very 
useful in many cases, but can never serve as a substitute for 
counting. The reader is referred to Ewing, p. 35, for details. 

ESTIMATION OF COMPARATIVE VOLUMES OF PLASMA 

AND CORPUSCLES. 

The hematocrit of Hedin, as modified by Judson Daland, 
is another indirect method of estimating the number of red 
and white corpuscles. It can not be recommended as a satis- 
factory substitute for counting. It simply ascertains the rela- 
tive volume of corpuscles and plasma in a drop of blood. A 
glance at a stained specimen of anaemic blood soon convinces 
one that corpuscles vary much in size in different diseases. 
In such cases inaccurate results are obtained with the hemato- 
crit. 



WRIGHTS METHOD. 69 

Method of Using the Hematocrit. — A graduated capil- 
lary tube is filled with blood. By means of a centrifugal 
machine the corpuscles are thrown to the bottom. The height 
of the blood column is noted on the scale, and the number 
of red and white cells calculated. 

ESTIMATION OF TOTAL BLOOD VOLUME. 

Blood examination, until recent years, has been limited to 
samples of blood from the peripheral circulation, and deduc- 
tions concerning the rest of the blood drawn therefrom. This, 
however, did not give a correct idea of the total blood vol- 
ume. The following method has been suggested by Haldane 
and Smith : The patient inhales a measured volume of CO ; 
after two or three minutes a few drops of blood are taken for 
analysis, and the percentage to which the haemoglobin has 
become saturated with carbonic oxide is estimated by the 
carmine method. 1 

ESTIMATION OF THE TIME AND COMPLETENESS OF 

COAGULATION. 

Normally, clotting occurs in about three minutes, but in 
the exanthemata, in the various forms of the hemorrhagic 
diathesis, in obstruction of the biliarv tract with or without 
jaundice, and in the various anaemias it may be very much 
delayed. 

WRIGHTS METHOD. 

This method consists in the use of a set of from six to 
twelve capillary tubes (0.01 to 0.0125 inch in diameter), into 
which a column of blood is aspirated. The tubes are placed 
perpendicularly in a rack, and at regular short intervals the 
blood is blown from each one of them. When it becomes 
impossible to blow it out, coagulation has set in, and the time 
is noted. 

Hayden thinks he can distinguish between secondary and 
pernicious ansemia by the incomplete formation of serum in 
the latter. 

1 See Journal of Physiology, xxii., p. 232 ; Ibid., xxv., p. 331. 



70 LESS FREQUENTLY APPLIED PROCEDURES. 

CRYOSCOPY. 1 

The Determination of the Freezing-point. — The Molecular 
Concentration of the Blood. — An important peculiarity of the 
blood, first established by Koranyi, is the fact that its molecu- 
lar concentration is constant under normal conditions, but is 
changed in certain diseases, and almost exclusively in affec- 
tions of the kidneys. These organs serve as regulators of the 
molecular composition of the blood, and this equalization is 
explained upon the theory of osmotic pressiwe. Since the 
osmotic pressure of a solution is proportional to the number 
of molecules, determination of the former would give the 
molecular weight. In practice this is accomplished in an 
indirect manner. Upon the basis of the fact that the lower- 
ing of the freezing-point of a solvent (e. g., water) by addi- 
tion of foreign substances is in proportion to the osmotic 
pressure of the solution, a determination of the molecular 
weight is directly obtained by measurement of this lowering. 

Determination of the freezing-point is done in Beckmann's 
apparatus. This consists essentially of a very delicate ther- 
mometer graduated in 100 parts, in which each Celsius degree 
is again divided into 100 degrees. The thermometer is placed 
in a glass cylinder in which the fluid to be examined is kept 
constantly agitated by means of a platinum stirrer. Glass 
cylinder, thermometer, and fluid are then placed in a freezing 
mixture at — 4° C, and the fluid cooled under constant stir- 
ring. A moment then arrives when the fluid suddenly con- 
geals. At the point of change from the fluid to the solid 
state heat is liberated, which causes the mercury column 
rapidly to rise to a certain point, where it remains stationary 
for some time — the physical freezing-point. On long stand- 
ing it again sinks and acquires gradually the temperature of 
the surrounding freezing mixture. If the freezing-point of 
distilled water is now determined in the same manner (the 
scale of Beckmann's thermometer is an arbitrary one and the 
zero point is not specifically designated), and the freezing- 
point of the solution is subtracted from that of the water, the 

1 From Kpvog = ice. 



CRYOSCOPY. 71 

figure indicating how much lower the solution freezes than 
the water is obtained. In blood this difference is — 0.56° C. 
We say, therefore, in brief: The freezing-point of the blood 
amounts to 0.56, and an especial designation, therefore, has 
been selected : " 3" while " J " indicates the freezing-point 
of the urine. The procedure in blood examination is as fol- 
lows : From a constricted vein of the arm (of course, under 
aseptic precautions) 15 to 20 cubic centimetres of blood are 
taken by means of puncture with a sharp cannula. The blood 
is then placed in the glass cylinder used for freezing and 
defibrinated by shaking with the platinum ring, when the 
freezing is at once begun. In a second glass cylinder the 
freezing-point of distilled water is determined each time. 
The latter procedure is considered necessary because the posi- 
tion of the mercury in the U-shaped Beckmann thermometer 
is easily subject to variations and because the thermometers 
with fixed point appear not to be reliable. After some 
practice the whole procedure, including venous puncture, 
requires about thirty minutes. The molecular concentration 
of the blood in health is shown by a lowering of the freezing- 
point of —0.55° to —0.57° C. On the other hand, this value 
undergoes an essential change — i. e., the freezing-point is 
lower when an affection of both kidneys exists. The degree 
of difference in comparison to the normal freezing-point of 
the blood is in proportion to the severity of the renal affec- 
tion. While in mild degrees of nephritis normal values are 
still found, the freezing-point becomes lower and lower with 
increased insufficiency of the kidneys. Lowerings to below 
0.70° C. have been observed. On the other hand, the differ- 
ential diagnostic and prognostic fact is to be emphasized that 
in unilateral renal affection, even when the latter has advanced 
to complete destruction of the organ, the freezing-point shows 
the normal height, provided the other kidney is healthy. 
From this we obtain the important law that a lowering of 
the freezing-point of the blood below — 0.58° C. almost 
invariably indicates a bilateral affection of the kidney (Len- 
hartz). 



72 LESS FREQUENTLY APPLIED PROCEDURES 

BACTERIOLOGICAL EXAMINATION OF THE BLOOD. 

For this examination a moderately large quantity of blood 
must be obtained under strictly aseptic conditions. Prepare 
the arm as for venesection, and when the veins are full insert 
a sterilized needle to which a sterilized syringe is attached. 
Suction is made, and as much blood as desired withdrawn and 
immediately expelled into the culture-medium before coagu- 
lation sets in. 

Of late, important work has been done in demonstrating 
the presence of the Bacillus typhosus in the blood, even before 
the Widal reaction can be obtained. As a result of improved 
technique the various bacteria, such as the streptococcus, staph- 
ylococcus, gonococcus, pneumococcus, etc., are much more fre- 
quently demonstrated in the blood than formerly. Rosenow l 
found pneumococci in 77 of 80 cases, and Kinsey 2 demon- 
strated pneumococci in 19 of 25 cases examined. 

Technique. — It is the opinion of all that have met with 
success that comparatively large amounts of blood and bouillon 
should be employed. Kinsey's results are particularly in- 
structive. He reports two series of cases of 25 each. In 
the first series from 8 to 9 cubic centimetres of blood 
were added to 50 cubic centimetres of bouillon, making a 
dilution of 1 : 6. The results were 3 positive and 22 nega- 
tive. In the second series 1 part of blood (3 to 6 cubic 
centimetres) to 15 or 20 parts of bouillon were employed, 
with the result that 19 cases were positive and 6 negative, 
most of the 6 negative cases being unfavorable cases. Cole 
employed both bouillon and litmus-milk. Kinsey and others 
prefer the bouillon medium. 

DISEASES IN WHICH DIAGNOSIS DEPENDS ON OR IS 
FACILITATED BY BLOOD EXAMINATION. 

1. Primary pernicious anaemia is characterized by the 
following deviations from the normal blood condition (Figs. 
19, 20, 21). 

1 Transactions of the Chicago Pathological Society, 1903, p. 265. 

2 Journal of the American Medical Association, March 19, 1904. 



DIAGNOSIS OF DISEASES BY BLOOD EXAMINATION. 73 

(a) The haemoglobin is greatly reduced, frequently to even 
20 per cent, or less. 

(6) The color-index is usually high, owing to the increase 
in the size of many of the red cells and the excess of haemo- 
globin which they contain. 

Fig. 19. 









4L ■• * '•'§.•;# 



o 




Elongated or oval corpuscles in a case of pernicious anaemia. (Cabot.) 



(c) The number of red corpuscles is greatly reduced. The 
average in Cabot's cases was about 1,200,000 per cubic milli- 
metre. The lowest reported count is that by Quincke, of 
148,000 per cubic millimetre. 

(d) The presence of unusual forms of red corpuscles, marked 
poikilocytosis, polychromatophilia, and nucleated red cells in 
which megaloblasts exceed normoblasts. 

(e) Oxygen capacity decreased — volume variable. 



74 LESS FREQUENTLY APPLIED PROCEDURES. 



(/) Blood-drop pale — may be streaked ; is remarkably fluid ; 
very slow in coagulating ; absence of rouleau formation. 

Rarity of blood-plates and loss of retraction on the part of 
the clot (Hayem). 

Considerable diminution in the number of leukocytes. 
Cabot's 110 cases averaged 3800. 

Fig. 20. 




Pernicious anaemia. 



X 350. Note the relatively large size and well-stained 
centres of the cells. (Cabot.) 



2. Secondary Pernicious Anaemia. — The blood condition 
is practically the same as in the primary form, differing only 
in its etiology. In the latter no definite cause can be found, 
but the former may be the result of parasites in the intestinal 
tract, frequent hemorrhages, etc. In spite of the pernicious 
blood condition, this variety of anaemia may recover under 
appropriate treatment, 



DIAGNOSIS OF DISEASES BY BLOOD EXAMINATION. 75 

Experience has shown that when the blood condition of 
pernicious anaemia is present (with the exception of the anae- 
mia due to the ankylostoma, etc.) the prognosis is always 
grave, and a fatal issue may be expected within a few years, 
more or less. The most important diagnostic point is the 
preponderance of megaloblasts over normoblasts or the pres- 
ence of a single gigantoblast. 

Fig. 21. 




Chlorosis. X 350. Note small size and pale centres. (Cabot.) 

Fatal Anaemia with Hypoplastic Marrow (Aplastic 
Anaemia). — This is a very fatal anaemia of which only a few 
cases have been reported. Marked reduction in the red and 
white cells and haemoglobin, with absence of nucleated red 
cells, great diminution in the percentage of poly nuclear neu- 
trophiles, and hypoplastic bone-marrow, are the chief blood 
signs. 



76 LESS FREQUENTLY APPLIED PROCEDURES. 

3. The Secondary Anaemias. — These are very numerous, 
arid vary in degree from the mildest to the most severe, the 
latter approaching the pernicious anaemias in blood changes. 

The mild forms are characterized by : (a) lack of haemo- 
globin ; (b) lowered specific gravity, with perhaps only slight 
reduction in the red count. (We see such cases in poorly 
nourished women and in those living in unhygienic sur- 
roundings.) 

Moderate cases show a more marked diminution in the 
haemoglobin and reduction in the specific gravity, endoglobular 
changes, poikilocytosis, changes in staining properties, dimi- 
nution in the average diameter of the corpuscles, with loss of 
power to form rouleaux, and slight leukocytosis. 

Severe cases show all of the above changes, together with 
reduction in the number of red cells and the presence of nor- 
moblasts. 

Very severe cases show all the above changes, with the 
addition of megaloblasts. 

The color-index, in contradistinction to that of pernicious 
anaemia, is low, there usually being a greater reduction in the 
haemoglobin than in the red cells. 

The blood examination in such cases throws light simply 
upon the blood condition, not upon the primary disease which 
is responsible for the blood state. 

Chlorosis. — In this variety of anaemia the following blood 
changes are found : 

(a) Blood color very pale in severe cases ; very fluid, but 
coagulates rapidly ; fibrin not increased ; specific gravity low, 
running parallel with the haemoglobin. 

(b) Red cells small, pale, and often deformed. The average 
count is in the neighborhood of 4,000,000, and seldom goes 
below 1,000,000. Nucleated red corpuscles (normoblasts) 
are rare. 

(c) White cells not increased, but there is lymphocytosis 
and occasionally eosinophilia. 

(d) Blood-plates increased. 

(e) Haemoglobin-index low, in contrast to that of pernicious 
anaemia, viz., a blood count of 4,000,000 red cells may furnish 



DIAGNOSIS OF DISEASES BY BLOOD EXAMINATION. 77 

only 40 to 50 per cent, of haemoglobin. It is most difficult 
to distinguish chlorosis from secondary anaemia. This is due 
chiefly to the presence of leukocytosis in the latter. It is 
true, however, that the complications of chlorosis usually pro- 
duce leukocytosis. 

According to Smith, the blood volume is greater than 
normal by more than one-half. He concludes that there is 
really a large absolute increase in the number of red and 
white cells disguised by an excess of plasma. Treatment 
diminishes the amount of plasma, but does not increase the 
oxygen capacity. Very often the blood examination only 
allows us to diagnose " chlorotic condition of blood," and is 
of value from the therapeutical standpoint, but does not throw 
light upon the nature of the primary disease. 

Leukaemia. — Blood examination is absolutely essential for 
the diagnosis of this disease, and enables us to distinguish its 
different forms. Leukaemia is of two kinds: myelogenous 
and lymphatic. 

Myelogenous Leukaemia. — Fresh drop — opaque in color, slug- 
gish in flow, difficult to spread, coagulation normal. The red- 
cell count varies with the stage of the disease ; on an average 
it is a trifle over 3,000,000; haemoglobin is usually dimin- 
ished ; color-index 0.6 in Cabot's cases. Nucleated red cells, 
chiefly normoblasts, are very numerous, even though the 
patient may not be anaemic. Variations in size and shape 
correspond with the degree of anaemia. 

White Cells. — The average number per cubic millimetre in 
Cabot's 44 cases was 438,000 ; the highest being 1,072,222, 
and the lowest 98,000. The ratio between the red and the white 
cells in this disease may be 1 : 2, and even 1:1. During the 
stage of improvement the white cells may number as low as 
10,000, and still show the characteristic type. 

In contrast to the poly nuclear cells of leukocytosis, the 
myelocytes are only slightly amoeboid. The chief character- 
istic of leukaemia is the presence of enormous numbers of 
myelocytes, often averaging as high as 35 per cent, of the 
w T hite cells. 

The poly(morpho)nuclear cells are relatively much dimin- 



18 LESS FREQUENTLY APPLIED P&OCEDURES. 

ished, but absolutely much increased. They show greater 
variation in size, staining properties, and size and shape of 
nucleus, than in any other disease. 

The lymphocytes are reduced in percentage from 20 to 30 
to 10.6 per cent. 

Eosinophils are absolutely much increased ; relatively they 
may or may not be. 

Polynuclear eosinophiles, dwarf and giant eosinophiles, and 
eosinophilic myelocytes may also be present. 

Fig. 22. 



,~ < T , *v 









Atypical leukocytes, seen in leukocytosis : 1, leukocytes with polar arrangement 
of nuclei (mitosis?); 2, 3, leukocytes with nuclei resembling those of myelocytes; 
4, leukocytes containing two kinds of granules. (Cabot.) 



The condition of leukaemic blood is polymorphous. There is 
no fixed type of cell ; each variety shades through intermedi- 
ate forms into some other variety ; no two cells are alike. 

Lymphatic Leukaemia. — This is divided into two varieties 
— chronic and acute. 



DIFFERENTIAL DIAGNOSIS-BLOOD EXAMINATION. 79 

Chronic : 

1. Red cells about 3,000,000 or lower; nucleated forms 
rare. 

2. White cells about 300,000. 

3. Small lymphocytes usually over 90 per cent. 

4. Myelocytes and eosinophiles very scanty. 
Acute : 

1. Red cells much diminished ; nucleated forms infrequent. 

2. Large forms of lymphocytes usually predominate. Many 
of them often show signs of degeneration. 

3. Neutrophils and eosinophiles very scanty. 

DIFFERENTIAL DIAGNOSIS THROUGH BLOOD EXAMI- 
NATION. 

Blood examination, including staining and differential 
counting, makes it possible to distinguish leukaemia from — 

(1) Hodgkin's disease ; 

(2) Tumors of spleen and vicinity ; 

(3) Enlargements of lymphatic glands from tuberculosis, 
syphilis, and malignant diseases ; 

(4) Hydronephrosis; 

(5) Large leukocytosis from any cause ; 

(6) Chronic malaria ; 

(7) Amyloid disease. 

Hodgkin's Disease. — Blood examination furnishes the only 
clinical means of distinguishing Hodgkin's disease from 
lymphatic leukaemia. The physical signs of enlarged glands 
are the same, but the negative character of the blood excludes 
lymphatic leukaemia. It can not, however, help us to exclude 
syphilis or tuberculosis (many believe Hodgkin's disease and 
tuberculosis of the glands to be identical) or malignant dis- 
ease, as the blood conditions may be the same in all these dis- 
eases. 

Splenomegaly. — In patients with anaemia and an enlarged 
spleen blood examination makes it possible to exclude leukae- 
mia of either variety. The majority of cases of spleno- 
megaly show an enlarged spleen together with a moderate 



80 LESS FREQUENTLY APPLIED PROCEDURES. 

anemia and a leukopenia. Blood examination, however, does 
not enable us to exclude a chronically enlarged spleen from 
other causes ; for example, an ague cake. 

In purulent affections the leukocytes, when treated with a 
preparation of iodine, give a definite reaction, which is termed 
iodophilia. 

Solution. — 

Iodii sublimat., 1 part ; 

Potassii iodidi, 3 parts ; 

Aqua dest., 100 " 
Acacia ad syrupum. 

This is painted on a slide and the unfixed cover-glass prep- 
aration pressed down upon it. In nonsuppurative diseases 
the red cells stain dark yellow ; white cells light yellow, with 
very refractile citron-colored nuclei. 

In purulent affections the protoplasm of the leukocytes 
stains brown, slight or intense, with deeply tinted flakes or 
granules. 

After an abscess is opened the color soon disappears. Cold 
abscesses do not produce this reaction. It may occur in 
pneumonia, in puerperal sepsis without localization, and in 
nonsuppurative terminal infections. 

Malaria. — The diagnosis can be made with absolute cer- 
tainty by finding Plasmodium malarise in the blood. 

There are three varieties of the malarial parasite : (1) ter- 
tian, (2) quartan, and (3) sestivo-autumnal. It is very seldom 
that the quartan or sestivo-autumnal parasite is found farther 
north than Baltimore, most of the cases in this latitude being 
of the tertian variety. There are certain differences in the 
morphology of these parasites which the beginner will find 
difficult to recognize. This is especially true of the young 
forms. 

There are two methods of examining the blood for malarial 
parasites: (1) fresh blood; (2) stained specimen. The fresh 
drop method is extremely useful for diagnosis, the study of 
the vibratory motion of the pigment, amoeboid motion of the 



DIFFERENTIAL DIAGNOSIS— BLOOD EXAMINATION 81 

parasite, exflagellation, escape of the parasite from the cell, and 
occasionally the formation of vacuoles. Slide and cover-slips 
should be thoroughly cleaned and polished. The slip is 
touched to a small drop of blood exuding from the finger and 
immediately placed upon the slide. The blood should spread 
in a thin layer one cell deep, in order that the flat surface 
of the cells can be seen. It is best examined with a y 1 ^ oil 
immersion. The beginner should secure the blood when the 
parasites are old and well developed, a few hours before the 
expected chill, as they are easy to recognize at this stage. 
Even an expert finds it impossible to be certain of his diag- 
nosis of the younger forms of malarial parasites in the fresh 
drop. It is very difficult to distinguish between the young 
hyaline forms and the presence of vacuoles, or crenation 
changes in the red cells. A mechanical stage is almost a 
necessity for accurate work. A negative fresh drop exami- 
nation should always be controlled by examination of the 
stained specimen. 

The flagellate bodies may be studied in the fresh drop (on a 
warm stage if possible). They usually appear in from ten to 
twenty minutes. They form chiefly from the larger tertian 
and sestivo-autumnal parasites ; less often from the quartan. 
They represent the male element in the sexual reproduction 
of the malarial parasite. They may be stained by keeping 
the films moist for ten to twenty minutes in a Petri dish con- 
taining wet blotting paper and sealed with vaselin. (The 
moisture favors the process of flagellation.) The preparation 
is then dried and stained. 

Staining Dry Specimens. — Spreads are made in the ordinary 
way, care being taken to secure a thin film. It is unneces- 
sary to fix them if Wright's stain is to be used. For stain- 
ing by other methods, they should be fixed in 95-97 per cent, 
alcohol, or in equal parts of alcohol and ether for fifteen to 
thirty minutes (though five minutes will suffice). 

By far the simplest and best method of staining the mala- 
rial organism is with Wright's stain. Most beautifully stained 
specimens, which even rival those done by the Nocht-Roman- 
owsky method, are obtained in a few minutes. The staining 
6— c,d 



82 



LESS FREQUENTLY APPLIED PROCEDURES. 



reaction is very similar to that of the Nocht-Romanowsky. 
Excellent colored plates can be found in Ewing, which illus- 



Fig. 23. 



Fig. 24. 





Fig. 25. 



Fig. 26. 





Fig. 23.— Tertian fever. (Cabot.) 

Fig. 24.— Tertian fever. Marked stippling of infected corpuscle. Single chrom- 
atin body. Achromatic zone very distinct. (Cabot.) 

Fig. 25.— Tertian. (Cabot.) 

Fig. 26.— Intracorpuscular. Segmenting body in tertian fever. Stippling of cor- 
puscle. (Cabot.) 

trate the working of this stain, and will help the reader in 

the study of the development and morphology of the parasite. 

The body of the malarial parasite stains blue, while the 



DIFFERENTIAL DIAGNOSIS— BLOOD EXAMINATION. 83 
Fig. 27. Fig. 28. 




Fig. 29. 



Fig. 30. 




Fia. 27.— Segmentation of malaria] organism in tertian fever. Stippling of cor- 
puscle. (Cabot.) 

Fig. 28.— Tertian fever. Double infection of corpuscle, one organism segment- 
ing. (Cabot.) 

Fig. 29.— Crescentic parasite distending a red blood-corpuscle. (Cabot.) 

Fig. 30.— Ovoid form of the sestivo-autumnal parasite distending a red blood- 
corpuscle. A portion of the corpuscle projects above the parasite and is much dis- 
torted. The dark line around the parasite also represents the remnants of the cor- 
puscle. (Cabot.) 



84 LESS FREQUENTLY APPLIED PROCEDURES. 

Fig. 31. 





w*^ 



Flagellate malarial organism. (Thayer.) 



color of the chromatin varies from a lilac color, through dif- 
ferent shades of red, to almost black. In the young forms 
of the tertian and sestivo-autumnal parasites the chromatin 
appears as a very dark-red spherical body, while in the older 




Fig. 32. 














DIFFERENTIAL DIAGNOSIS— BLOOD EXAMINATION. 85 











A 
to 



m 







The first twelve figures show the malarial Plasmodium. It is a pale amoeboid 
body inside the red corpuscle. It increases in size at the expense of the corpuscles. 
In the last four of the twelve it is enlarged, and contains pigment-granules derived 
from the haemoglobin. The figures of the fourth row show progressive stages in the 
process of cleavage of the Plasmodium, and shifting of the pigment-granules. In 
the fifth row the process of cleavage is seen to be completed, and final isolation of 
the spores has taken place. The dark granules are pigment-granules. The last row 
shows oval parasites — Laveran's corpuscles observed in atypical cases of malaria. 
(From Golgi, " Studien uber Malaria" Fortschritte der Median, Bd. iv., Talfel III.) 



and 



may 



forms it has a more lilac or purplish-red color, 
appear in the form of a reticulum. 

In the intermediate forms the color of the chromatin may 
present variations between these extremes. If examined in 
water instead of Canada balsam, the distinct red color of the 
chromatin is more apparent. 

The blood-plates situated seemingly within the red cor- 
puscle must not be mistaken for the young form of the 
parasite. 

The young parasite of all three kinds presents by this 



86 LESS FREQUENTLY APPLIED PROCEDURES. 

method a dark-red spherical nucleus, and a cytoplasm which 
is usually in the form of a definite ring. 

Some of the red cells harboring parasites show by this 
method dark-red staining granules. 

The Nocht-Romanowsky is an excellent stain, but is more 
complicated and requires several hours for its completion. 
For its application, see page 28. The remarks on the Wright 
stain apply very well to this stain. 

Eosin and methylene-blue is the method commonly used, but 
is much inferior to Wright's. The solutions mentioned on 
page 27 are used. This eosin staining should be light. 

Thionin Method. — Fix specimens five minutes in 95 per 
cent, alcohol, to 100 c.c. of which has been added 1 c.c. of 
formalin. Stain one to three minutes in the following mixt- 
ure : saturated alcoholic solution of thionin, 20 c.c. ; 20 per 
cent, carbolic acid, 100 c.c. The fixing solution must be 
fresh ; the staining fluid at least one week old. The rings 
are deeply stained, and the specimens do not fade. 

TERTIAN PARASITE. 

Morphology. — The malarial parasite is introduced into the 
circulation by means of a certain species of mosquito 
(Anopheles). The tertian variety goes through a life-cycle in 
the human blood in forty-eight hours. The youngest form 
appears in the red corpuscle during or soon after the chill, as 
an oval body 2 fi in diameter. 

It is identical with the spore of the parent rosette. Stained 
according to the Wright method, it shows an outer rim of bluish 
protoplasm, enclosing a single large nuclear body, which 
takes a dark-red stain, which is usually enclosed or accom- 
panied by a clear achromatic substance — "the milk zone" of 
Gautier. 

In the fresh specimen this young form is refractive, but 
does not show the complete lack of color or the sharp out- 
lines that the vacuoles of the red corpuscles do. They change 
their position, but not their shape, and are never pigmented. 
The red corpuscle is often swollen. The parasite grows, 



TERTIAN PARASITE. 87 

assumes a ring shape, and usually preserves this up to the pre- 
segmenting stage. A few grains of pigment may be found in 
the rings. 

Large Ring Forms. — In from six to eight hours the ring has 
enlarged and developed an outgrowth which is actively 
amoeboid in the fresh condition, throwing out numerous 
threads. The chromatin divides into several large granules. 

Spheroidal Bodies. — The body and nucleus develop rapidly 
in size, and toward the end of twenty-four hours the parasite 
occupies three-fourths of the swollen cell in the form of a 
spheroidal body. The pigment is abundant — mostly found in 
the outer zone. There is a gradual subdivision of the chro- 
matin granules. 

Third Quarter. — The full-grown parasite is homogeneous, 
richly pigmented, and occupies at least four-fifths of the 
swollen cell. Ewing thinks that between the twenty-fourth 
and fortieth hours of the cycle very little change takes place 
in the structure of the parasite. The nucleus occupies the 
entire ring, and undergoes changes associated with reproduc- 
tion. 

Presegmenting bodies begin to appear in the blood eight to 
ten hours before the chill. The body of the parasite becomes 
reticulated. 

The completed process of segmentation shows itself in the 
tertian rosettes , which appear in the blood three to four hours 
before the chill, but are most abundant just before it. These 
rosettes are of large size, and have from ten to twenty spores. 
These spores separate, and appear in the plasma as small free 
hyaline bodies. They soon enter the red cells and begin a 
new cycle of intracorpuscular existence. 

Instead of segmenting, the parasite sometimes escapes from 
the red cell and appears as an extracoi tr puscular form. This is 
about the size of a red blood-cell, and does not exhibit 
amoeboid movements. They sometimes slowly disintegrate 
and disappear ; at other times they show fragmentation, vacu- 
olation, or flagellation. 

Fragmentation is a division by the process of budding. 
Occasionally vacuoles form in the large free parasite. 



88 LESS FREQUENTLY APPLIED PROCEDURES. 

Flagellation. — In a small percentage of cases the extracor- 
puscular bodies become flagellated. Their pigment collects in 
the centre and becomes very active, and several thread-like 
processes or flagella are protruded from the periphery. These 
are several times longer than the diameter of the corpuscle 
and have slight bulbous enlargements. These flagella may 
whip about vigorously, causing great disturbance among the 
red cells. They sometimes break off. The significance of 
flagellation is now understood, the flagella being a form of 
spermatozoon and associated with the reproductive process 
(MacCallum). 

Double Infection. — The blood may be infected with two sets 
of the tertian parasite (double tertian), causing a paroxysm 
daily. This fact is recognized by finding in the blood one set 
of full-grown parasites and another of half-grown parasites. 
Each set requires the full forty -eight hours for the completion 
of its cycle. 

The quartan parasite requires seventy-two hours for the 
completion of its cycle. The youngest form in the stained 
preparation can not be distinguished from the tertian organ- 
ism, but it may be suspected from the smaller red cell. In 
the fresh specimen the organism is more highly refractive 
than the tertian. It becomes more easy of identification 
after a few hours' development, because it takes the form of 
a ring which is smaller, more compact, and more richly and 
coarsely pigmented. In the fresh specimen at this stage the 
amoeboid motion is slower and the organism is more re- 
fractive. 

It is easier to distinguish these two parasites during the 
presegmenting stage. Quartan presegmenting bodies are 
much more numerous. They are more coarsely reticulated, 
relatively smaller and more richly pigmented, and lie in 
shrunken cells. 

Blood may be infected with one, two, or three sets of quar- 
tan parasites, each ripening on a certain day, and forming a 
single, double, or triple quartan infection, with one chill 
every three days, or two chills every three days, or a chill 
daily. 



TERTIAN PARASITE. 89 

The sestivo-autumnal parasite in its youngest form resem- 
bles the tertian and quartan ; it is smaller and less refractile 
than either. 

Signet-ring. — At an early period it assumes a ring shape ; 
many of these rings develop a thickening of one segment, 
giving them the appearance of a signet-ring. Multiple infec- 
tion with the young form is common, three rings often being 
found in a single cell. Ewing reports having found seven 
rings in one red cell in smears from the marrow of a fatal 
case. 

In the majority of cases the ring forms seen in the 
peripheral blood fail to show any pigment. The segmenting 
forms resemble those of the tertian, but are smaller ; the cell 
is shrunken and the spores are smaller, but not less numerous. 
Segmentation takes place in the spleen or in other internal 
organs. Before and during the paroxysms no parasites at 
all may be found in the peripheral blood. 

Crescentic bodies are very striking objects, and are found 
in cases of sestivo-autumnal fever. The adult form does not 
appear until the fifth to seventh day after the paroxysm. 
Their length is slightly greater than the diameter of the red 
corpuscle. They are crescentic or elliptical masses of proto- 
plasm, containing near their centre a collection of coarse dark 
pigment-granules. A dim curved line can be seen on the 
concave side of the crescents, joining the two ends. In stained 
specimens this faintly stained line is seen to be the remnant 
of a red corpuscle. Little is known of the nature and sig- 
nificance of crescents. They are persistent and resistant to 
treatment. 

The transverse segmentation, lateral budding, and vacuola- 
tion are probably degenerative changes. Crescents frequently, 
on being exposed to the air for a few moments, assume the 
spheroidal form, and soon from one or more points pseudo- 
podia (so-called flagella) shoot out with active lashing move- 
ments. 

The sestivo-autumnal parasite is associated with the irregu- 
lar and protracted, continued, and remittent, chronic and 
cachectic, or the more malignant forms of malarial disease. 



90 LESS FREQUENTLY APPLIED PROCEDURES 

It is seldom seen in temperate regions, but is abundant in the 
tropics. 

Melansemia. — By this is meant the pigment left after the 
breaking up of the segmenting forms; it is free in the plasma. 

Melaniferous Leukocytes. — Leukocytes which have taken up 
these pigment-granules, or the granules remaining from dis- 
integrated parasites, are termed melaniferous. 

Filariasis. — The filarise found in the blood of man are em- 
bryos, the adult form being lodged in the lymphatics. There 
are four varieties : Filaria nocturna, Filaria diurna, Filaria 
perstans, and Filaria Demarquaii. 

The only variety which is found at all frequently in the 
United States is Filaria nocturna. It is common in the 
tropics, and many cases have been reported in the southern 
part of the United States. Its adult form is the nema- 
tode, Filaria Bancrofti. The embryo is found in the blood 
only during sleep or at night. It is about 0.3 mm. long 
and 0.0075 mm. in diameter, small enough to pass through 
the capillaries. It is present in small numbers. The live 
worm exhibits active wriggling motions, knocking the blood- 
cells about. It has a slender, worm-like shape ; the poste- 
rior end is tapering and pointed, the anterior rounded and 
blunt. It is enclosed in a delicate membrane, which does 
not interfere with its movements. 

Filaria diurna is found in the peripheral blood in the day- 
time; perstans continuously. Both are found in Western 
Africa, and may be present in the blood for years without 
producing symptoms. 

Relapsing Fever. — The spirillum of relapsing fever (Spiro- 
chseta Obermeieri) is a rare parasite, easily found in the fresh 
blood or stained preparation. Sometimes it is present in 
large numbers during and for a day or two before the parox- 
ysms of this disease. They are slender, wavy or spiral fila- 
ments, 30 to 40 /jl long, and actively motile. 



TE YPANOSOMIA SIS 



91 



TRYPANOSOMIASIS. 

The trypanosome has of late acquired great importance 
because of its discovery in man in cases of sleeping sickness, 
and because of its possible etiological association with several 
other tropical diseases. Bruce demonstrated the organism in 
the blood in 13, and in the cerebrospinal fluid obtained by 
lumbar puncture, in all of 38 cases of sleeping sickness. 
Castellani had previously found the parasite in the cerebro- 
spinal fluid in 20 of 34 cases. Dutton, in 1902, was the first 
to demonstrate the occurrence of trypanosomes in man. In 

Rg. 33. 




Trypanosoma gambiense in human blood. (Dutton.) 

animals, such as frogs, dogs, rats, ground-hogs, and horses, 
their occasional presence had long been known. Novy and 
McNeal succeeded in cultivating the Surra Trypanosome of 
the Philippines. 

Trypanosoma gambiense (Dutton) is from 8 to 25 ju long, 
and from 2 to 2.8 fx broad. It is provided with an undulat- 
ing membrane and a flagellum, which starts from a centro- 
some or micronucleus, lying in the posterior end of the 
animal, and projects somewhat beyond the anterior end (Fig. 
33). There is an oval nucleus which is centrally located and 



92 LESS FREQUENTLY APPLIED PROCEDURES, 

is made up of chromatin granules. In the wet preparation 
the organism exhibits slow spiral movements. It is found 
free in the blood-plasma, but may also be seen in the interior 
of leukocytes. They stain with Wright's stain similar to the 
malarial organism. Their number in a blood preparation is 
not large. During apyrexia they are not found. Infection 
probably occurs through mosquitoes. 

The Leishman-Donovan Parasites. — Leishman and Donovan 
have recently described a new parasite found in the spleen, 
pulp and blood, intra vitam, in cases of Dumdum fever. 
(Dumdum is a station seven miles from Calcutta.) This is a 
small round or oval body, 2 or 3 ft in diameter, occurring 
in enormous numbers among the spleen cells and red cor- 
puscles. Stained by Komanowsky's method they show a 
quantity of chromatin, of a very definite and regular shape, 
which clearly differentiates them from blood-plates or pos- 
sible nuclear detritus. This chromatin appeared in the form 
of a more or less definitely circular mass or ring, applied to 
which, though apparently not in direct connection with it, is 
a much smaller chromatin mass, usually in the form of a short 
rod set perpendicularly or at a tangent to the circumference 
of the larger mass. The outlines of the sphere or oval 
enclosing these masses of chromatin are only faintly visible 
by this method of staining. These bodies are scattered freely 
among the cells, as a rule, isolated one from another, but 
here and there aggregated into clumps composed of 20 to 50 
members (Leishman). 

SPOTTED FEVER. 

Wilson, Chowning, and Anderson have described a small 
organism called the Pyroplasma hominis, which is found in 
the blood of patients suffering with the so-called spotted fever 
of Montana, Oregon, and Nevada. It is described as an 
intracorpuscular, amoeboid, non-pigmented organism. It 
sometimes has a terminal dark spot, and sometimes occurs in 
pairs when it is not amoeboid. It is transmitted by the 
Rocky Mountain tick (Derma-centor reticulatus). 

Craig [American Medicine, December 10, 1904) has made 



SPOTTED FEVER. 93 

special investigations of the blood in various diseases, and is 
convinced that these supposed parasites are nothing but areas 
in the blood-corpuscles devoid of haemoglobin — vacuoles 
probably. The imperfect and difficult staining is simply 
due to the fact that some of the stain extended into the areas. 
Craig finds similar appearances in other diseases. He also 
points out the improbability that the disease is due to animal 
parasites. Neither the blood nor the urine shows such 
changes as are observed in Texas fever; the blood is rather 
thicker than normal. Stiles has also been unable to confirm 
the earlier reports, and in general shares Craig's views. 

Bacteremia. — Bacteriological examination of the blood, 
though a difficult procedure, is of great value in recognizing 
the different forms of bacteremia. Typhoid fever may be 
recognized in this way before the development of the Widal 
reaction by the detection of Bacillus typhosus in the blood. 
The gonococcus, Diplococcus lanceolatus of pneumonia, and 
the different forms of pus organisms have been demon- 
strated in the blood by special cultural methods, thus 
establishing the diagnosis of different forms of bacteremia. 
In malignant endocarditis this examination is of great 
value. 

The blood is secured with a syringe from one of the veins 
at the bend of the elbow, under strict aseptic precautions. 
Because of the bactericidal power of the blood, it is difficult 
to grow the bacteria ; consequently large quantities of fluid 
media, broth, etc., should be used — a proportion of 100 parts 
of the media to 1 of the blood. A fairly large quantity of 
blood is required — 0.5 c.c. — because in most cases bacteria 
are not numerous in the peripheral circulation. For details 
of the method, readers should consult text-books on bacte- 
riology. 

Leukopenia. — An absolute reduction in the number of 
leukocytes below the lowest normal limit in the circulating 
blood is termed leukopenia or hypoleukocytosis. It is the 
opposite of leukocytosis or hyperleukocytosis. The lowest 
normal limit is usually given as 5000 per cubic millimetre. 

It is rather seldom in any condition that the leukocytes 
fall much below 3000. Koblanck reports a remarkable 



94 LESS FREQUENTLY APPLIED PROCEDURES 

case in an epileptic man twenty-five years of age. In a care- 
ful examination of 20 stained cover-glass preparations he 
found only 1 leukocyte. Cabot refers to an unusual case 
of lymphatic leukaemia in which the white count fell from 
40,000 to 419 per cubic millimetre in the course of three 
weeks as the result of the development of an acute septicae- 
mia. There are two classes of leukopenia : (1) physiolog- 
ical ; (2) pathological. 

Physiological leukopenia may occur after prolonged cold 
baths, short hot baths, and stimulation of sensory nerves. A 
change in the distribution of the leukocytes in the vessels 
takes place as a result of vasomotor influences. Malnutrition 
and starvation are prominent factors in causing a reduction 
in the number of leukocytes. The faster Succi showed a 
decrease in his leukocytes from 14,530 to 861 per cubic mil- 
limetre after a seven-day fast. This number increased to 
1530 on the eighth day, and remained at about this figure 
during the remaining twenty-two days of the fast. If dis- 
ease is excluded, the number of leukocytes, especially the 
poly nuclear, may be taken as an index of the patient's nutri- 
tion, a low count indicating poor nutrition. 

Pathological Leukopenia. — It is rather difficult to sepa- 
rate leukopenias and a simple absence of leukocytosis. 
The fact that some of the most important diseases (when 
devoid of complications) show an absence of leukocytosis is 
a valuable aid in diagnosis. The following diseases are 
included in this list : typhoid fever ; tuberculosis — including 
incipient phthisis, miliary tuberculosis, tuberculous perito- 
nitis, tuberculous ostitis and periostitis, tuberculous pleurisy, 
tuberculous pericarditis. 

If during the course of these diseases a leukocytosis 
develops, it points to the presence of a new factor ; in typhoid 
fever, for instance, one of its numerous complications should 
be suspected and looked for, such as phlebitis, perforation, 
hemorrhage, peritonitis, abscess, bronchitis, etc. 

Pulmonary tuberculosis inevitably becomes a mixed infec- 
tion as the lesions increase, with a resulting leukocytosis. 

DaCosta states that leukopenia, or at least an absence of 
leukocytosis, may occur during the course of the following 



SPOTTED FEVER. 95 

additional infectious diseases : measles, influenza, malarial 
fevers, Malta fever, and leprosy. 

A combination of an intense infection and feeble resisting 
power may result in a very low white count, as in certain 
cases of pneumonia and appendicitis. 

A well-marked leukopenia may be expected in about one- 
fourth of the cases of chlorosis and about three-fourths of 
the cases of pernicious anaemia. It is also found in some 
severe cases of secondary anaemia and in splenomegaly. 
Chronic gastro-enteritis in infancy reduces the white count 
below the normal. 

An intercurrent infection may produce a leukopenia, as in 
Cabot's case referred to above. 

Various investigators have produced a decrease in the 
number of leukocytes by the administration of different sub- 
stances hypodermatically. Bohland found that it followed 
the injection of ergot, sulphonal, tannic acid, camphoric acid, 
atropine, agaracine, and picrotoxine. Delezene injected 
various anticoagulant substances — peptone, diastase, and 
eel-serum — with a resulting marked leukopenia. The leuko- 
penic phase which precedes the development of leukocytosis 
lias been referred to in the chapter on Leukocytosis. 

In typhoid fever there is a gradual decrease in the number 
of leukocytes after the first week, the lowest counts being 
found during the fifth and sixth weeks. This rule, accord- 
ing to Winter, does not hold good in all cases, but it is so 
constant that if in a given case of noneruptive fever the 
number of leukocytes is normal or subnormal, it is a strong 
point in favor of the diagnosis of typhoid fever. There is a 
progressive diminution in the percentage of polymorphonu- 
clear cells, which continues into the stage of early convales- 
cence. The percentage of lymphocytes is increased through- 
out the fever, the increase being most marked in the stage of 
convalescence. The degree of the leukopenia corresponds in 
a general way to the severity of the disease (not taking into 
account the effect of complications). Counts as low as 9000 
and 3000 are not rare. In pernicious anemia the white-cell 
count runs parallel with the red-cell count and the hemo- 
globin per cent. In some cases it is very low, falling to 1000 



96 LESS FREQUENTLY APPLIED PROCEDURES. 

per cubic millimetre. As stated above, leukopenia is found in 
about three-fourths of the cases of pernicious anaemia, which 
is in marked contrast to the tendency toward leukocytosis in 
secondary anaemias. 

Ehrlich believes that in these conditions there is a lessened 
proliferative function of the bone-marrow, which results in a 
diminution in the output of leukocytes by this organ. 

Leukocytosis. — By leukocytosis is meant an increase of 
the number of leukocytes in the circulating blood above that 
which is normal for the individual. This increase must aifect 
chiefly the polynuclear leukocytes or each variety in such a 
way that the relative proportions of the different leukocytes 
remain the same as in health. 

Normal Percentage of Each Variety in the Adult. — 

/ \ f Small lymphocytes, 20-30 per cent. 

| Large lymphocytes, 4-8 



(b) Polymorphonuclear neutrophils, 62-70 

(c) Eosinophiles, 0.5-4 

(d) Mast-cells, 0.1-0.5 



Myelocytes represent a pathological variety of leukocytes ; 
hence, an increase of leukocytes involving especially the myelo- 
cytes is not considered a leukocytosis, but represents a special 
blood disease, which is considered under the heading Leukaemia. 

Again, an increase of leukocytes involving especially the 
lymphocytes is not a leukocytosis, but is termed a lymphocy- 
tosis or a lymphatic leukaemia. 

Some authorities prefer the terms hyperleukocytosis and 
hypoleukocytosis to indicate an increase and a decrease in the 
number of leukocytes, using the word leukocytosis to mean 
the normal number of leukocytes. 

The normal number of leukocytes varies within quite a 
wide range in healthy adults (5000 to 10,500). People in a 
poor condition of nutrition, but with no special disease, have 
a low leukocyte count with a reduced percentage of poly- 
nuclear cells ; while those in vigorous health have a high leu- 
kocyte count, even approaching a slight leukocytosis, with an 
increased percentage of polynuclear cells. 

The estimation of the number of leukocytes is of great 



SPOTTED FEVEB. 97 

value in the diagnosis and prognosis of disease, and aids ma- 
terially in operative decisions, when considered in connection 
with other diagnostic and prognostic data. Considered by 
itself it is useless. 

It is highly important to keep in mind the fact that a leu- 
kocytosis may be physiological. 

Varieties of Physiological Leukocytosis. — (a) Newborn ; (b) 
digestion; (c) pregnancy; (d) post-partum ; (e) after violent 
exercise, massage, and cold baths ; (/) moribund state. 

In the newborn there is a leukocytosis varying from 17,000 
to 21,000 — greatly increased by digestion. This gradually 
decreases as the child grows older, till about the sixth year, 
when it approaches the normal adult standard. It must be 
kept in mind that the leukocyte count of a child is greatly influ- 
enced by the backwardness or forwardness of its development. 

Attention to digestion leukocytosis is often overlooked in the 
estimation of leukocytes and the deductions drawn therefrom. 
After a meal rich in proteids the leukocyte count may increase 
in health about 33 per cent. A vigorous person w T hose fast- 
ing leukocyte count is 9000 may have a count of 12,000 three 
to four hours after a meal. The best time to make a fasting 
leukocyte count is before breakfast, since during the day there 
is more or less digestion leukocytosis most of the time. In 
certain diseases — other than those of the digestive tract — there 
may be quite a marked digestion leukocytosis. Cabot gives 
the following examples : 

In a case of pneumonia the count before food was 10,400, 
after food 21,700 ; neurasthenia, before food 7500, after food 
13,500. 

Any disease of the gastro-intestinal tract, whether func- 
tional or organic, may prevent the appearance of the diges- 
tive leukocytosis. 

In chronic gastritis there may be an absence of digestion 
leukocytosis, or it may be slight and late in appearing. In 
dilated stomach it may be absent. In the majority of cases 
of cancer of the stomach it does not occur. 

Pregnancy. — Most primiparse show a moderate degree of 
leukocytosis during the later months of pregnancy, averaging 

7— C D, 



98 LESS FREQUENTLY APPLIED PROCEDURES. 

about 13,000. It is not so common in multipara. The fact 
that in this condition there is no digestive leukocytosis sug- 
gests that the pregnancy leukocytosis may be simply a pro- 
longed digestive leukocytosis. 

The fact that there is normally a moderate leukocytosis 
during the post-partum period is of value because it might be 
taken as an evidence of sepsis. 

Violent exercise, massage, and cold baths such as the 
typhoid bath, cause a moderate temporary leukocytosis — com- 
parable to the digestion leukocytosis. 

Moribund, or terminal, leukocytosis occurs during the ter- 
minal stages of diiferent diseases, and in most cases is due to 
peripheral stasis. In some cases it is thought that the ter- 
minal infections may be responsible. The increase in white 
cells is moderate, seldom exceeding 20,000 or 30,000, and is 
usually in the polymorphonuclear cells. Occasionally, as in 
the case of pernicious anaemia reported by Cabot, the increase 
in the lymphocytes is so marked as to resemble lymphatic 
leukaemia. 

Pathological leukocytosis. — Cabot makes the following 
classification : 

(1) Posthemorrhagic. 

(2) Inflammatory. 

(3) Toxic. 

(4) Malignant disease. 

(5) Therapeutical and experimental. 

THEORY EXPLAINING PATHOLOGICAL LEUKOCYTOSIS. 

Present evidence tends to show that this process is a general 
one involving the entire circulatory system — that a drop of 
blood from the finger or the ear may be taken as an index of 
the blood condition in the deeper vessels of the body. Leu- 
kocytosis is symptomatic of an excessive output and rapid 
development of leukocytes by the bone-marrow, due to the 
influence of chemotaxis. 

The chemotactic theory may be stated as follows : The 
presence in the blood of certain chemical substances, pro- 
duced by infective agents, is capable of exerting both an 



THEORY OF PATHOLOGICAL LEUKOCYTOSIS. 99 

attractive and a repellant influence upon the amoeboid leuko- 
cytes. If cells are attracted by such substances, the phe- 
nomenon is known as a positive chemotaxis; if they are 
repelled, it is called negative chemotaxis. This effect upon 
the cells of the blood may be produced by bacteria or their 
products — necrotic tissue — which have gained entrance to the 
circulation, and thermal and mechanical irritants. It would 
seem that different varieties of leukocytes — polynuclear neu- 
trophiles, eosinophils, lymphocytes — respond to different 
stimuli ; in one instance we have an ordinary leukocytosis, 
as in pneumonia, in which the polymorphonuclear cells are 
chiefly increased ; in another, as in trichiniasis, an eosino- 
philia ; in a third a lymphocytosis. 

It seems reasonable to conclude that leukocytosis is a conser- 
vative process on the part of nature, and represents an attempt 
to destroy the infectious agent or its product by mechanical 
means — i. e., phagocytosis; or by chemical means — the produc- 
tion of chemical substances (alexins) which act as bactericidal 
or antitoxic agents. Grabit-Schewsky states that these proc- 
esses are most active at the period of maximum leukocytosis. 

Just previous to the development of leukocytosis there is 
usually a stage in which the leukocyte count is low. This is 
called by Lowit the leukopcenic phase. Goldscheider and 
Jacob have proved that this is dependent purely upon an 
altered distribution of the cells in favor of the deeper vessels. 

Pathological leukocytosis differs from the physiological in 
being usually of larger extent and of greater duration, and 
in being almost always accompanied by a relative and abso- 
lute increase in the polymorphonuclear leukocytes. There 
is also a change in the cell-structure in certain cells. A small 
percentage of the polymorphonuclear cells resemble myelo- 
cytes, having a nucleus which is on the border-line between 
the two cells : 1 to 3 per cent, of the cells have become so 
altered that they can not be distinguished from myelocytes. 

Posthemorrhagic Leukocytosis. — Following a large 
haemorrhage there is usually within an hour a considerable 
leukocytosis, from 16,000 to 18,000. In haemorrhage from 
the stomach this disappears again in a day or two, while in 
ordinary traumatic haemorrhage it persists longer. 

t o 



100 LESS FREQUENTLY APPLIED PROCEDURES. 

Inflammatory and Infectious Leukocytosis. — To the 

clinician the determination of leukocytosis in the numerous 
infectious and inflammatory conditions is of more practical 
value, from the standpoint of diagnosis and prognosis, than 
the leukocytosis in all other conditions. 

In the consideration of this variety of leukocytosis and 
the deductions to be drawn from it, it is well to keep in mind 
the following facts : 

There is no direct connection between leukocytosis and 
fever, since many febrile processes — typhoid fever, for instance 
— run their entire course, if uncomplicated, without leukocy- 
tosis, even showing a hypoleukocytosis. 

Purulent and gangrenous processes usually cause a 
higher leukocytosis than serous processes (compare Empyema 
and Pleurisy); the amount of leukocytosis depends on- the 
severity of the infection and the resisting power of the patient. 

A leukocytosis which increases from hour to hour suggests 
an acute spreading inflammatory process, and its detection is 
of great value, in cases of acute appendicitis, in influencing 
the surgeon regarding operation and prognosis. Wright and 
Joy (Medical Neivs, April 5, 1902) come to the following con- 
clusions from a study of 124 cases of appendicitis in which 
they have blood records, and about as many more in which 
they have no records : 

1. The leukocyte count is a valuable aid to prognosis in 
appendicitis. 

2. This aid is distinct from its diagnostic value. 

3. A high stationary or an increasing count indicates a 
morbid condition of increasing severity which demands opera- 
tion, no matter what the clinical symptoms may be. 

4. A low stationary or a decreasing count indicates that 
the severity of the case is abating, and that an operation may 
be safely postponed. Cases in which a falling count is 
accompanied by unmistakable signs of a generally bad con- 
dition form rare exceptions to this general principle, and in 
them there is no chance of error. 

5. No arbitrary set of prognostic values to be assigned to 
various degrees of leukocytosis can be constructed. The 
important point is to follow any scheme in which one learns 



THEORY OF PATHOLOGICAL LEUKOCYTOSIS. 101 

to have confidence, provided the essential principle be pre- 
served. 

6. The count indicates when operation should be performed 
for the best interests of the patient. 

7. Circumstances often render it desirable to postpone 
operation in appendicitis. Study of the blood enables it to 
be determined whether this may be done with safety, and 
often renders such postponement permissible. 

When appendical abscess is walled off and stationary, leuko- 
cytosis is less than in the advancing process, and does not 
increase from hour to hour. 

Leukocytosis is present in the following inflammatory 
diseases (Cabot) : 

Asiatic cholera, relapsing fever, typhus fever (according to 
the majority of observers), scarlet fever, diphtheria and fol- 
licular tonsillitis, syphilis (secondary stage), erysipelas, bubonic 
plague, yellow fever (some cases). 

Pneumonia, smallpox (suppurative stage), malignant endo- 
carditis, puerperal septicaemia, and all pysemic and septicemic 
conditions, actinomycosis, trichinosis, glanders, acute multiple 
neuritis (febrile stage), acute articular rheumatism, septic 
meningitis and cerebrospinal meningitis, cholangitis, chole- 
cystitis, empyema of gall-bladder, acute pancreatitis, endo- 
metritis, cystitis (some cases), gonorrhoea. 

Abscesses of all kinds and situations — felon, carbuncle, 
furunculosis, tonsillar and retropharyngeal abscess, appendi- 
citis, phlebitis (some cases), pyonephrosis, perinephritic abscess, 
pyelonephritis, osteomyelitis, empyema, psoas and hip abscesses 
when not simply tuberculous, abscess of lung, liver, spleen, 
ovary, prostate ; salpingitis, pelvic peritonitis, epididymitis. 

Pericarditis, peritonitis, arthritis (serous or purulent, non- 
tuberculous), conjunctivitis. 

Gangrenous inflammations of the appendix, lung, bowel, 
mouth (noma). 

Many inflammatory diseases of the skin, such as derma- 
titis, pemphigus, pellagra, herpes zoster, prurigo, some cases 
of universal eczema. 

A miscellaneous class producing leukocytosis (toxic 
under Cabot's classification) includes that of illuminating-gas- 



102 LESS FREQUENTLY APPLIED PROCEDURES. 

poisoning, quinine-poisoning, rickets, uric acid diathesis, gout, 
acute yellow atrophy of the liver, advanced cirrhosis of the 
liver (some cases), especially with jaundice, acute gastroin- 
testinal disorders (ptomains?), chronic nephritis, usually in 
uraemic cases, after injections of tuberculin and thyroid ex- 
tract, normal salt solution (intravenous), after ingestion of 
salicylates, potassium chlorate, or phenacetin, during or after 
prolonged chloroform narcosis, ether narcosis (according to 
some observers). 

Malignant Diseases and Leukocytosis. — The position of the 
tumor, its size, rapidity of growth, the number, size, and 
position of its metastases, and the resisting power of the 
patient — all have a marked effect upon the number of leuko- 
cytes in malignant disease. 

There may be a leukopenia in cancer of the oesophagus, 
due to the starvation which a new growth in that location 
causes. If the cancer is small and without metastases, as in 
the early epithelioma of the lip, the leukocyte count is nor- 
mal. Excessively high counts are never found. In rapidly 
growing and extensive neoplasms of the lung, liver, and kid- 
neys, counts of 50,000, 40,000, and 28,000 have been made. 
Sarcoma usually produces a more frequent and larger leuko- 
cytosis than carcinoma. When all cases are considered, ab- 
sence of leukocytosis is perhaps more common in malignant 
disease than its presence. 

Therapeutical and Experimental. — Pohl found that most of 
the so-called tonics and stomachics produce a slight leukocy- 
tosis in animals. Winternitz injected a large variety of sub- 
stances subcutaneously, and found that the degree of leukocy- 
tosis was parallel to the degree of local reaction excited. 

Lymphocytosis is an absolute and relative increase in the 
circulating lymphocytes. The ordinary white count can not, 
of course, determine this fact, but resort must be had to the 
differential count of stained films. A moderate white count 
might show a lymphocytosis. If lymphocytosis is associated 
with an increase in the total white count, it can not be dis- 
tinguished from lymphatic leukaemia except by the history 
and physical signs. Taking the adult blood as our standard, 
lymphocytosis is normal for healthy infants. Certain of the 



THEORY OF PATHOLOGICAL LEUKOCYTOSIS. 103 

diseases of infancy increase the lymphocytes remarkably, 
such as cholera infantum, rickets, various intestinal troubles, 
scurvy, hereditary syphilis, and especially pertussis, which 
disease, according to Meunier, may quadruple the lympho- 
cytes. There is no rule governing the size of the lympho- 
cytes ; sometimes it is the larger, sometimes the smaller, and 
often no division can be made between the two. 

In many debilitated conditions in the adult the percentage 
of lymphocytes is increased, due simply to a diminution in 
the number of poly nuclear neutrophiles ; and this must not 
be called a lymphocytosis. 

Diagnostic value of lymphocytosis is seen chiefly in the 
diagnosis of lymphatic leukaemia when associated with the 
presence of glandular tumors. Whooping-cough must first 
be proved absent. If associated with eosinophilia, it may 
suggest obscure syphilitic disease. 

Eosinophilia is an absolute increase in the number of eosino- 
phils in the circulating blood. There is a variation from 25 
to 500 per cubic millimetre in the healthy adult blood. 
Physiologically, eosinophilia occurs in young infants, in 
women during the menstrual period, and after coitus. 

Pathologically, it has been reported in a large number of 
diseases, but from the standpoint of practical diagnosis is of 
more value in trichiniasis than in any other disease. The 
following list of diseases in which eosinophilia is found with 
the greatest regularity is taken from Da Costa : 



Diseases of the Skin. 


Helminthiasis. 




Dermatitis herpetiformis. 


Ankylostomiasis. 




Eczema. 


Ascaris lumbricoides 


infec 


Leprosy. 


tion. 




Lupus. 


Oxyuris vermicularis 


infec- 


Pellagra. 


tion. 




Pemphigus. 


Taenia mediocanellata 


infec- 


Prurigo. 


tion. 




Psoriasis. 


Trichiniasis. 




Scleroderma. 






Urticaria, 







104 THE STOMACH 

Miscellaneous Conditions. Diseases of the Bones. 

Postfebrile malarial fever. Hypertrophy. 

Pneumonia. Osteomalacia. 

Rheumatic fever. Malignant neoplasms. 

Scarlet fever. 

Septicaemia. 

Bronchial asthma. 

Splenomedullary leukaemia. 

QUESTIONS. 

In what diseases is the coagulation time of the blood altered ? 

Describe Wright's method of estimating the coagulation time of the blood. 

What is meant by cryoscopy ? Describe the technique and philosophy of the 
procedure. 

W T hat bacteria are found in the blood ? 

Describe the technique of blood culture. 

Distinguish between secondary anaemia and pernicious anaemia. 

Distinguish between chlorosis and pernicious anaemia. 

Differentiate myelogenous from lymphatic leukaemia. 

In what diseases is a differential diagnosis dependent upon blood examina- 
tion ? 

What is meant by iodophilia ? 

Mention the different methods of examining the blood for the malarial 
parasite. 

Name the varieties of malarial organisms. 

What are the points of distinction between these different plasmodia? 

Describe the appearance of the stained tertian parasite in its various stages 
of development. 

What is the significance of segmentation and flagellation ? 

Describe the parasites of filariasis, relapsing fever, dumdum fever, spotted 
fever, and trypanosomiasis. 

What is leukopaenia, leukocytosis ? Explain the philosophy of each. 

In what diseases are they of diagnostic value ? 

What is digestive leukocytosis ? 

What is lymphocytosis ? 

Of what diagnostic value is eosinophilia ? 



CHAPTER VIII 



THE STOMACH. 

APPARATUS REQUIRED FOR GASTRIC WORK. 

Stomach-tube with bulb. 
Politzer bag for aspiration. 
Atomizer bulb for inflation, 



REAGENTS BEQUIEEJD FOB STOMACH WORK. 105 

Rubber apron — Turck's if desired. 

Graduates, 100 cc, 200 c.c. 

Urine jars, 1000 c.c^ 

Small beakers or whiskey glasses. 

Graduated volume pipettes, 2 c.c., 5 c.c, 10 c.c. 

Glass funnels 3 and 6 inches in diameter. 

Burette graduated to 0.1 c.c, with Shellbach's band, or a 
float, fitted either with a pinchcock or stopcock. 

Burette stand, either tripod or retort stand with double 
burette clamp. 

Test-tube stand. 

Small test-tubes. 

Cork-puncher. 

Glass rods, glass tubing. 

Filter-paper. 

Slides and cover-slips. 

Porcelain capsules, 1\ inches, 3 inches. 

Thermostat. 

Microscope. 

Special 1 ounce drop reagent bottles with vitrified labels. 

Glass irrigator, 3000 c.c. capacity, with irrigator spout, cap, 
and irrigator frame. 

Glass funnel for syphon stomach-tube (Kny-Scheerer Co. 
catalogue, No. 18,055). 

Suction flask, with single perforated rubber cork. 

Aspirator, same as in blood work, for rapid filtration 
(Fig. 1). 

REAGENTS REQUIRED FOR STOMACH WORK. 

Decinormal sodium hydrate solution (prepared by chemist). 
Phenolphthalein solution (1 per cent., alcoholic). 
Sodium alizarin sulphonate solution, 1 per cent., aqueous. 
Dimethyl-amido-azo-benzol solution, 0.5 per cent., alcoholic. 

Gunzburg reagent : 

Phloroglucin, 2 grammes ; 

Vanillin, 1 gramme ; 

Absolute alcohol, 30 cc. 



106 THE STOMACH, 

Dilute hydrochloric acid, U. S. P. official. 

Carbolic acid solution for Uffelmann's test : Put a few c.c. 
of carbolic acid in a 4-ounce bottle of distilled water ; shake, 
let stand, and use supernatant liquid. 

Ferric chloride solution, officinal. 

LugoPs solution. 

Sodium chloride. 

Glacial acetic acid. 

Nitric acid. 

Ether. 

Pepsin in 0.5-gramme powders or tablets. 

Bottle of Mett albumin tubes or simple disks. 

Litmus-paper. 

Congo-red paper — soak filter-paper in solution of dye, dry 
and cut into strips. 

Dimethyl paper — soak filter-paper in solution of dye, dry 
and cut into strips. 

Methylene-blue stain. 

OBJECTS OF STOMACH EXAMINATIONS. 

1. To show the condition of the stomach secretions. 

2. To show the condition of the motor power of the 
stomach. 

3. To show the condition of the absorptive power of the 
stomach. 

4. To show the presence of abnormal organic constituents, 
such as yeast, sarcines, bacteria, blood, pus, tissue bits from 
stomach-wall or new growth. 

5. To show the size, position, and shape of the stomach. 

GENERAL REMARKS. 

The student must bear in mind the fact that the normal 
stomach reacts differently to varying kinds of stimuli. Food 
is the natural stimulant, and useful conclusions concerning 
gastric digestion can only be drawn following the administra- 
tion of test-meals. The stomach also reacts differently to 
different foods, both as regards the quality and quantity of 



GENERAL REMARKS. 107 

food ; for instance, a test-meal containing meat stimulates the 
secretion of more hydrochloric acid than a test-meal of carbo- 
hydrates. A large meal stimulates the secretion of more of 
the stomach juices than a small meal, and remains in the 
stomach longer. 

Following the administration of test-meals, free hydro- 
chloric acid does not appear in the contents until the proteids 
of the food are saturated with this acid, thus forming the 
combined hydrochloric acid. 

The analysis of gastric juice obtained by mechanical and 
electrical stimulation differs materially from that obtained 
after the ingestion of food ; consequently its analysis is of no 
special clinical value. 

The reader is cautioned against placing too much reliance 
for diagnosis and therapeutics on the chemical analysis of 
the stomach contents. Even more important is it to direct 
attention to the motor power, size of the stomach, evidences 
of fermentation, ulceration, or new growths. 

The symptoms in diseases of the stomach are due to fer- 
mentation and its products, excess of hydrochloric acid, and 
hyperesthesia of the gastric mucous membrane (nervous in- 
fluences). 

Our knowledge of the process of digestion comes from 
analyses of the stomach contents removed after the taking of 
food at different periods during the process of digestion. 

The gastric juice differs rather widely in health, depending 
on the individual, the character and quantity of food, and 
the period of digestion at which it is removed. Even with 
the same sort of test-meal, removed after the same length of 
time, it will vary from day to day ; consequently it is w r ell to 
give a series of three test-meals either of the same kind or, 
better, an Ewald-Boas breakfast, a Riegel dinner, and an 
ordinary meal. The average test-meal of bread and water 
does not furnish a fair test of the stomach's secreting capacity. 
It does not appeal to the appetite and by the stimulation of 
the senses of sight, taste, and smell stimulate the production 
of the psychical gastric juice, which Pawlaw has proved to be 
an important factor. 



108 THE STOMACH. 

Analysis of Gastric Juice, Obtained during Fasting, 
containing Saliva, per Mille : 

Specific gravity, 10020.000 

Water, ' 994.400 

Organic material, 3.190 * 

Free hydrochloric acid, 0.200 

Chloride of sodium, 1.460 

Chloride of potassium, 0.550 

Chloride of calcium, 0.060 
Phosphate of calcium, magnesium, 

and iron, 0.125 
TEST-MEALS. 

The test-meals most commonly employed are the following : 
Ewald and Boas Test-breakfast. — One roll or two slices 
of white bread with crust removed (35 to 70 grammes) ; 350 c.c. 
of water or weak tea. The dry bread is chewed thoroughly, 
then washed down with the liquid. Remove one hour after 
the beginning of the breakfast. Under normal conditions 
the following should be found (Van Valzah and Nizbet) : 

*"»»* • • • 30t <>50c.c.. • • { y 1Sf£r 

Thirty minutes. Sixty minutes. Ninety minutes. 

Total acidity 20 to 30 50 to 60 30 to 40 

Combined acids ........ 20 to 30 40 to 50 25 to 35 

FreeHCl 10 to 15 5 to 10 

Digestive power of filtrate (Hammerschlag's test, about 90 
per cent.). Filtrate in dilution of 1 : 3000 with normal HC1 
solution digests disk of albumin after remaining in thermo- 
stat at 37° C. for twenty-four hours. 

Rennet ferment coagulates milk in dilution of 1 :40. 

Rennet zymogen coagulates milk in dilution of 1 : 160. 

Free HC1 appears in thirty minutes, reaches its height in 
about one hour, and, diminishing, continues to the end of 
digestion. 

Acetic acid and potassium ferrocyanide give a slight cloudi- 

1 Pepsin, 3, 



TEST-MEALS. 109 

ness after the first half-hour, up to early digestion. The 
biuret reaction (rose) runs the same course. Fehling's solu- 
tion is reduced during the first hour. LugoPs solution gives 
a brownish-purple color during the first one and a half hours. 

There should be no blood, a small amount of mucus, per- 
haps a little bile, and a small number of bacteria ; no organic 
acids ; no signs of fermentation, such as long bacilli, sarcines, 
or yeast. 

The stomach should be empty in two to two and a half 
hours after the beginning of the meal. 

Boas Test-breakfast. — A tablespoonful of rolled oats is 
added to 1000 c.c. of water ; this is boiled down to 500 c.c. 
A little salt may be added. Remove one hour later. 

Indications. — This meal is employed in suspected cases of 
cancer of the stomach, where it is important to determine the 
presence of lactic acid, since it contains none of this acid, 
while test-meals containing bread do. The stomach should 
be thoroughly washed out the night before. 

The chemical findings are about the same as those for the 
Ewald-Boas test-breakfast. 

Riegel Test-dinner. — Soup, 400 c.c; finely chopped or 
scraped beef, 200 grammes ; a slice or tw r o of wheat bread 
(50 grammes) ; and a glassful of water. Remove four hours 
later. 

Amount . 40 to 80 c.c. 

Two hours. Three hours. Four hours. 

Total acidity 40 to 50 45 to 70 60 to 80 

Combined HC1 40 to 50 45 to 60 50 to 60 

FreeHCl to 5 10 to 20 

Free HC1 appears in about two and a half hours, continues 
about two hours, and disappears about twenty minutes before 
the stomach becomes empty. 

The cloudiness with acetic acid and potassium ferrocyanide 
and the biuret reaction (rose) begin near the end of the first 
hour, and disappear during the last fourth of the period of 
digestion. Very few striated muscle-fibres can be found. 
The stomach should be empty in five hours. 

Hammerschlag, about 90 per cent. 



110 THE STOMACH 

Rennet ferment and zymogen are the same as in the test- 
breakfast. 

Lugol's solution produces a brownish-violet coloration. 

Ordinary Meal. — It is a good custom to examine occasion- 
ally the stomach contents removed four hours after the patient's 
average dinner, and make the analysis as after the regular 
test-meals. 

Contraindications to the Use of the Stomach-tube.— 
Chief among these are aneurysm of the aorta and inflamma- 
tory conditions of the oesophagus. Advanced arteriosclerosis, 
especially with involvement of the coronary arteries, with a 
history of attacks of angina pectoris, forbid the passage of 
the stomach-tube except in those accustomed to its use. Con- 
trary to common opinion, it is frequently used as a thera- 
peutical measure in cases of valvular heart lesions, even dur- 
ing the stage of incompensation. Cancer and ulcer of the 
stomach, instead of always contraindicating its use, are at 
times strong indications for its use unless there is a history 
of recent hemorrhage. Good judgment should govern one in 
the selection of cases. 

Stomach-tube. — The tube most commonly employed is 
manufactured by the Goodrich Rubber Company. The most 
satisfactory tube is made of soft rubber and has a bulb 
attachment ; sizes 21 E, 22 A, 33 F. Its outside diameter 
is ^g- inch, lumen ^ inch. A smaller tube is used for 
children. The entire length of the tube, including the 
bulb, is about 65 inches ; length to bulb is about 43 inches. 
A white ring indicates the distance to which the tube should 
be introduced in the average case. One soon learns the 
correct distance by experience. The tube most often em- 
ployed has an opening at the end and one on the side, a 
short distance above. Some prefer a tube with a blind 
end and lateral openings, because there is less danger of 
damaging the stomach mucous membrane by suction into the 
terminal opening. The tube should not be too flexible. It 
is well to cut it in two about 12 inches from the funnel end 
and insert a piece of glass tubing, in order the better to 
inspect the character of the washings as they pass through. 



REMOVAL OF THE STOMACH CONTENTS. Ill 

A rubber or glass funnel can be used. A special glass funnel 
for this purpose is manufactured by the Kny-Scheerer Co. 

Patients with syphilis, tuberculosis, and cancer should have 
tubes for their exclusive use. 

Passing the Tube. — The patient should be told that it is 
not a serious operation, and that it will not interfere with his 
breathing. There is usually no need of introducing the fingers 
of the left hand into the mouth to guide the tube. Moisten 
the tube in water or glycerine, hold it in the fingers of the right 
hand, as one would a pen, four to five inches from the end, 
aim directly at the middle of the posterior pharyngeal wall, 
cautioning the patient not to bend his head backward too far, 
tell him to swallow, and push the tube forward without hesi- 
tancy. In most cases it will enter the canal readily. With 
the left arm thrown around the patient's head from behind, 
the tube is held in place between the index and middle fin- 
gers, and rapidly pushed into the stomach with the right 
hand. Occasionally a spasmodic contraction of the oesopha- 
geal muscles at the isthmus of the fauces or lower down will 
obstruct the passage. Steady pressure will overcome this 
resistance in a few seconds. If the tube is quite flexible, it 
may not enter the isthmus at all, but bend to the side and 
pass around the patient's mouth. An extremely irritable 
pharynx may be sprayed w 7 ith cocaine, or a pledget of cotton 
may be soaked in a 5 per cent, solution of cocaine and sucked 
for five minutes, care being taken not to swallow the saliva. 
Such procedures are almost never necessary. The tube may 
meet an organic stricture, due to cancer, ulcer, or tumor 
pressing from the outside. 

REMOVAL OF THE STOMACH CONTENTS. 

The contents may be obtained in three ways : 
(1) Self-expression. — By bearing down, as at stool, or by 
coughing, the abdominal muscles and stomach are made to 
contract and thus force out the contents. Slight vomiting 
movements may be produced by moving the tube back and 
forth, thus facilitating the expulsion. 



112 



THE STOMACK 
Fig. 34. 




Showing on upper shelf drop reagent bottle, suction flask, and platinum wire 
and loop ; on lower shelf, Politzer bag and atomizer bulb ; on table, beginning at the 
left, funnel for syphon stomach-tube, Cowie burette stand, reagent bottle, rack for 
6UCtion flask, etc., bulbed stomach-tube, irrigator with spout cap. 



(2) Suction. — The modified Politzer bag of 
the aspirator of Boas can be used. (See Fig. 34.) 



Ewald or 
Tubes are 



REMOVAL OF THE STOMACH CONTENTS, 113 

now manufactured with the Boas aspirator attached. With 
the fingers of the left hand the tube is compressed between 
the bulb and the stomach. The bulb is now compressed, the 
first pressure relaxed, and the tube beyond the bulb then 
compressed, and the pressure on the bulb relaxed. The bulb 
sucks the stomach contents into itself. They are now ex- 
pelled by again compressing the tube toward the stomach, 
and then compressing the bulb. The Politzer bag when used 
is first compressed and then attached to the stomach-tube, and 
on expanding draws the contents into itself. The aspirator 
used in cleansing the blood pipettes will be found very conve- 
nient for this purpose. 

(3) Position and Gravity. — With the patient in the hori- 
zontal or knee-elbow position, the contents can sometimes be 
more easily removed. 

The tube should be just through the cardia and held in the 
mouth to prevent it dragging on the larynx. 

Failure to obtain contents may be due to several causes : 

(1) The stomach may be empty. Cases are met with in 
which the test-breakfast is forced into the bowel in less than 
half an hour. 

(2) The tube may be plugged with food or mucus. Com- 
pression of the Boas bulb or the Politzer bag may free the 
tube. An extra effort on the part of the patient may dislodge 
the obstruction. The tube may be introduced too far or not 
far enough. 

It may be necessary to remove the tube, cleanse it, and 
introduce it again. 

The introduction of water for syphon purposes renders the 
analysis unsatisfactory, and is not to be recommended. If 
unsuccessful in obtaining the stomach contents by the above 
methods, very often enough can be obtained for analysis by 
firmly comjjressing the tube with the fingers and withdrawing, 
the tube being in many instances partially filled with stomach 
contents. 



8— c. d. 



114 THE STOMACH, 

EXAMINATION OF THE STOMACH CONTENTS. 

Macroscopical Examination. — (a) Quantity. — The quan- 
tity varies much with the size of the stomach, condition of 
the motor power, presence of obstruction, size of meal, and 
period at which it is removed. 

(6) Odor. — The contents in health have a characteristic 
stomach odor. In fermentative conditions there is a disa- 
greeable, rancid odor. 

In health, following a test-meal, the contents should be 
moderately fluid, not thick and tenacious ; the food is fairly 
well digested and broken into small pieces, yellowish in color, 
and on standing separates into two layers — lower solid, upper 
liquid. 

A small amount of mucus is present ; there should be no 
macroscopical blood unless it comes from irritation of the 
oesophagus by the tube. A small amount of bile is often 
found when the tube is passed on those unaccustomed to its 
use. Pus should not be present. 

In disease the quantity may be diminished or very much 
increased. There may be great excess of mucus, which is 
easily recognized by its appearance. Food eaten many hours, 
even days, before may be present. Fresh red blood, or dark 
altered blood, excess of bile, a brownish scum in which sar- 
cines are often found, pieces of gastric mucous membrane, or 
bits of tissue from new growths or ulcers, all should be looked 
for. The naked eye usually detects the presence of bile. 
This examination is most satisfactorily made by pouring the 
residue after filtration upon a plate and examining with the 
aid of teasing-needles. 

Microscopical Examination of Normal Contents. — The 
findings vary with the meals. Vegetable cells, starch-gran- 
ules, altered meat-fibres, a few bacteria, a few red and white 
cells (result of tube irritating throat and oesophagus), fat- 
globules, possibly leptothrix, may be found. 

Microscopical Examination of Abnormal Contents. — 
This shows in different cases undigested meat-fibres, vegeta- 
ble cells, numerous red cells, pus-cells, sarcines, yeast-cells, 



EXAMINATION OF THE STOMACH CONTENTS. 115 

numerous bacteria, most important of which are the lactic 
acid bacilli. (Plate X.) These are better recognized by a 
study of the figures than by description. Sarcines, yeast- 
cells, and lactic acid bacilli are all signs of fermentation. 
Whenever a bit of the stomach mucous membrane is obtained, 
it should be sectioned and examined by a pathologist. It is 
recognized under the microscope by the special arrangements 
of cells. In cases of suspected carcinoma or atrophic gastritis 
such examination is extremely valuable. 

It has been claimed that the presence of lactic acid bacilli 
(Oppler-Boas) is quite positive evidence of cancer of the 
stomach, but too much stress must not be placed on them as 
evidence, as observers of late years have found them rather 
frequently in non-malignant conditions. 

Pus and blood are recognized by their appearance under the 
microscope, as described in other chapters. 

If necessary, the hsemin crystal test or the guaiacum test 
may be applied for the demonstration of blood. 

Sarcinae occur in characteristic squares, resembling cotton 
bales. 

Yeast-cells appear as oval bodies 3 to 10 /i long, showing 
the budding formation. There may be chains of three or 
four, or more commonly one larger body with a small one 
springing from it. 

Oppler-Boas Bacillus. — This is a long, large, non-motile 
bacillus, usually growing in chains which take a zigzag 
course. Frequently pairs of bacilli are seen joined together 
at an angle. 

Ralston Williams has succeeded in growing these bacilli 
on glucose-agar. 

They may be stained with methylene-blue. Under the oil 
immersion they appear made up of short rods. 

Filtration of Stomach Contents. — For rapid work a suc- 
tion flask is attached to the aspirator and the contents filtered. 
An ordinary funnel and filter-paper can be used, but the 
process is slow if much mucus is present. 



116 THE STOMACH. 



CHEMICAL ANALYSIS OF GASTRIC JUICE. 

Qualitative Tests. — Free acid of any kind turns Congo- 
red solution or paper a bright blue. Free organic acids can 
not be distinguished from free mineral acids bv this test. 
Acid salts do not give the reaction. 

Test.— A strip of Congo-red paper is dipped into the 
stomach juice, or to a few cubic centimetres of Congo-red 
solution (made by dissolving a bit of the powder in water) 
a few drops of stomach filtrate are added. 

Free Hydrochloric Acid. — This acid is recognized very well 
by Gitnzberg's test. Two or three drops of phloroglucin 
vanillin solution and an equal amount of filtrate are placed 
in an evaporating-dish and slowly heated over a flame, care 
being taken not to burn the contents. If free hydrochloric 
acid is present a beautiful rose-red color appears, especially 
at the periphery of the drop. This is due to the formation 
of minute red crystals. 

Dimethyl-amido-azo-benzol paper is a yellow bibulous paper 
which strikesa red color in the presence of free hydrochloricacid. 

Free Organic Acids. — Uffelmann's test is most commonly 
employed. 

Application. — To a small amount of carbolic acid solution 
of any strength a drop of ferric chloride solution is added ; a 
very dark-blue results ; distilled water is added till this solution 
becomes an amethyst-blue color. A few drops of the filtrate 
are added. If lactic acid is present in moderate amount, it 
becomes a canary yellow ; if in small amount, a greenish yellow. 

The reaction is unsatisfactory. Free HO clears up the 
blue solution, acetic and combined HC1 give it a yellowish- 
brown color ; and butyric acid a grayish opalescent appearance. 

Kelling's Test. — Kelling's is a more reliable test for lactic 
acid. It is applied as follows : 5 c.c. of gastric juice are 
diluted with 10 volumes of water and treated with 1 or 2 
drops of a 5 per cent, aqueous solution of ferric chloride. 
In the presence of lactic acid a distinct greenish-yellow color 
is seen if the tube is held to the light. A positive reaction 
is obtained only in the presence of lactic acid. 



CHEMICAL ANALYSIS OF GASTRIC JIUCE. 117 

Strauss' Test — Strauss' apparatus is filled with gastric 
juice to the mark 5 c.c., then ether is added to the 25 c.c. line. 
After shaking thoroughly the separated liquids are allowed to 
escape by opening the stopcock until the 5 c.c. mark is 
reached. Distilled water is then added to the 25 mark, and 
the mixture treated with 2 drops of the official tincture of 
the sesquichloride of iron, diluted in the proportion of 1 : 10. 
On shaking, an intensely green color appears if more than 1 
pro mille of lactic acid is present, while a pale green is ob- 
tained in the presence of 0.5 to 1 pro mille. Small amounts 
of lactic acid do not show with this test. 

The exact quantitative estimation of lactic acid is not of 
clinical value. If so desired, Boas' method may be used, for 
a description of which the reader is referred to Simon or 
( v. Jaksch. 

The recognition of butyric, acetic, and fatty acids is not 
important. The first two are usually recognized by their 
odor, especially if they are heated. 

Quantitative Determination of the Acidity of the 
Gastric Juice. — The best results are obtained by selecting 
one good method for constant use. Such a one is 

Topfer's Method. — This requires a burette, graduated 
pipettes, 3 small beakers, decinormal sodium hydrate solu- 
tion, and 3 color reagents, solutions of phenolphthalein, 
sodium alizarin sulphonate, and dimethyl-amido-azo-benzol. 

Solutions containing phenolphthalein turn pink in the pres- 
ence of an alkali, becoming permanently pink when the mixt- 
ure becomes even faintly alkaline. 

Sodium alizarin sulphonate is stated to be unaffected by 
hydrochloric acid in combination with proteid. 

Dimethyl-amido-azo-benzol in alcoholic solution becomes 
red in the presence of free hydrochloric acid. 

The following determinations are made by means of color 
reactions : 

1. Total acidity. 

2. Combined hydrochloric acid. 

3. Free hydrochloric acid. 

4. Organic acids and acid salts. 



118 THE STOMACH. 

Procedure. — The stomach contents are filtered : 

1. Total acidity : 

a. By means of a graduated volume pipette place 10 c.c. 
of filtrate in a beaker or whiskey glass. 

b. Add 2 drops of phenolphthalein (indicator). 

c. Titrate with decinormal sodium hydrate solution, adding 
it drop by drop, stirring after the addition of each drop, until 
the first permanent pink is detected. 

(This color reaction indicates that the acid filtrate has been 
made slightly alkaline by the addition of sodium hydrate, since 
phenolphthalein solutions turn pink in the presence of an alkali.) 

Read off the number of cubic centimetres of sodium hydrate 
required to bring about this end-reaction ; for example, 10 c.c. 

2. Combined hydrochloric acid: 

a. Place 10 c.c. of filtrate in a beaker. 

b. Add 2 drops of sodium alizarin (indicator). 

c. Titrate with sodium hydrate solution as in (1) until a 
permanent pure violet color is obtained. 

Read off the number of cubic centimetres of sodium hydrate 
required to bring about this end-reaction ; for example, 6 c.c. 
This figure does not indicate the combined hydrochloric acid, 
but instead the entire acidity minus the combined hydro- 
chloric, since alizarin does not react to hydrochloric acid com- 
bined with proteids. Hence the combined hydrochloric is 
calculated by subtracting 6 c.c. from 10 c.c. = 4 c.c. 

3. Free hydrochlonc acid : 

a. Place 10 c.c. of filtrate in a beaker. 

6. Add 2 drops of dimethyl-amido-azo-benzol (indicator). 
(The mixture will turn red in the presence of free HC1.) 

c. Titrate with sodium hydrate until the mixture turns a 
lemon yellow. 

Read off the number of cubic centimetres required ; for 
example, 2 c.c. 

The indicator (dimethyl) reacts to free mineral acids, but is 
not affected by organic acids unless present in more than 0.5 
per cent. 

4. Organic Acids and Acid Salts. — Subtract the acidity 
due to combined HC1 and free HC1 from the total acidity 



SCHEME ILLUSTRATING THE ABOVE PROCEDURES. 119 



and the result is the organic acids and acid salts ; for exam- 
ple, 10 c.c. — (4 c.c. + 2 c.c.) = 4 c.c. 

To illustrate the estimation of per cent, of acid in the 
above calculations. 

One cubic centimetre of the decinormal sodium hydrate 
solution represents 0.00365 gramme of hydrochloric acid. 

Total acidity =10 c.c. X 0. 00365, or 0.0365 gramme for 
every 10 c.c. of filtrate used ; or for 100 c.c. of filtrate 0.3650 
gramme or per cent. 

Combined HCl= 4 c.c. X 0.00365, or 0.01460 gramme for 
every 10 c.c. of filtrate used ; or for 100 c.c. of filtrate 0.1460 
gramme or per cent. 

Free HCl = 2 c.c. X 0.00365, or 0.00730 gramme for every 
10 c.c. of filtrate used; or for 100 c.c. of filtrate 0.0730 
gramme or per cent. 

Organic acids and acid salts = 0.3650 — (0.1460 + 0.0730) 
or 0.1460 gramme or per cent. 

Combined HCl = 0.1 460 per cent. 
Free HCl = 0.0730 

Organic acid and 1 ~ -m^a 

acid salts / ' 



a 



Total acidity 



= 0.3650 " 



SCHEME ILLUSTRATING THE ABOVE PROCEDURES. 



1. Phenolphthalein 
indicates 



2. 



i 

\ Total acidity 

) The entire 
I acidity ex- 
f cept com- 
J bined HCl 

3. Dimethyl-amido-azo- 1 ^ nni 

benzol indicates j * ree MU 

4. Organic acids and 1 1 /o i \ 

acid salts j 1 <^+°> 



Sodium alizarin 
sulphonate in- 
dicates 



f Free HCl, com- 
I bined HCl, 
j organic acids 
|^ and acid salts. 

f Free HCl, or- 
l ganic acids and 
acid salts. 

| Free HCl. 



120 THE STOMACH, 

a. Total acidity, 10 c.c. 

b. Combined HC1, 4 c.c. 

c. FreeHCl, 2 c.c. 

c/. Organic acids and acid salts, 4 c.c. 

Substitute for Percentage Calculation. — The number 
of cubic centimetres of decinormal sodium hydrate solution 
required to bring about the end color reactions in 100 c.c. 
of stomach filtrate in each of these calculations is used to 
indicate the degree of acidity. 

For example : If in estimating the total acidity 10 c.c. of 
filtrate were used, and it required 10 c.c. of sodium hydrate 
solution to bring about the end-reaction, it would require 100 
c.c. of sodium hydrate to bring about this reaction if 100 c.c. 
of filtrate were used. Consequently, total acidity is repre- 
sented by 100. If only 1 c.c. of filtrate is used, the number 
of cubic centimetres of sodium hydrate is multiplied by 100. 

Example : 

10 c.c. of filtrate. Sodium hydrate. Figure. Per cent. 

Total acidity 10 c.c. 100 0.3650 

Combined HC1 4 c.c. 40 0.1460 

Free HC1 ........ 2 c.c. 20 0.0730 

Organic acids and acid salts. 4 c.c. 40 0.1460 

It is helpful to notice that each 25 of acidity corresponds approximately 
to jo per cent, by weight. 

SHORT METHOD. 

In many stomach analyses it is necessary to determine only 
the total acidity and free hydrochloric acid. 

A unique method for determining these figures is the fol- 
lowing : 

a. Place 10 c.c. of filtrate in a beaker. 

6. Add 2 drops of dimethyl (indicator) and determine the 
amount of free HC1 present by titration with sodium hydrate. 

c. Add to this same filtrate 2 drops of phenolphthalein, 
and continue the titration with sodium hydrate till the first 
permanent pink results. The total acidity is represented Jby~ 
the entire number of cubic centimetres of sodium hydrate used. 

It frequently happens that not sufficient stomach contents 
are obtained to furnish 10 c.c. of filtrate for each of the three 



SHORT METHOD. 121 

titrations, and the few cubic centimetres required for the 
digestion test. Under these circumstances 2 c.c. or 5 c.c. 
may be used and calculations made accordingly. 

If the normal pipette is used for measuring the filtrate, the 
last drop should not be blown out. It is recognized by the 
presence of a white ring near its tip. 

Digestion Test. — Following the determination of the 
acidity of the gastric juice, the next test is for the presence 
of pepsin. 

Common Method. — If free hydrochloric acid has been de- 
monstrated to be present, a small test-tube is partially filled 
with the filtrate and a small disk of coagulated egg-albumin 
added to it. This is placed in the thermostat for twenty- 
four hours and examined from time to time. If free HC1 has 
been proved absent or in very small quantity, another test- 
tube should be prepared in the same way and a couple of 
cubic centimetres of a 0.4 per cent, solution of HC1 added. 
Two or three drops of official dilute HCL may be used 
instead. This second test-tube will furnish evidence of pep- 
sinogen, since free HC1 changes it into pepsin. 

Digestion is shown by the periphery of the disk becoming 
translucent ; and a rough idea of the amount of pepsin can 
be gained by noting the depth to which this translucent area 
extends. 

The egg-albumin disks are prepared as follows : An egg is 
boiled hard, shell removed, and the white carefully separated 
from the yolk. With a cork-borer numerous cylinders of the 
white are removed and cut into disks of the same size and 
preserved in glycerine. Before use the glycerine should be 
washed off with water. 

Mett Method of Determining Peptic Digestion. — Eal- 
ston Williams describes this method as follows : 

" Briefly described, glass tubes filled with coagulated egg- 
albumin are placed in 2 to 4 c.c. of gastric juice and kept in the 
incubator for ten hours. At the end of this time the tubes are 
removed and the number of millimetres of albumin digested is 
estimated. This is ascertained by measuring the portions of 
the ends of the tubes that are clear, including also the clouded 



122 THE STOMACH. 

or opalescent zone, if one be present. For this purpose a scale 
graduated to 0.5 mm., a small lens magnifying 2 to 3 diameters, 
and a small black glass plate are employed. With very little 
practice one can correctly read fifths of a millimetre. The 
digestion which goes on within the first ten hours, according 
to Ssamojloff, corresponds to the normal period of stomach 
digestion. Franz Jung states that from 5.5 to 5.9 mm. 
should be digested in ten hours ; however, the results obtained 
in the clinical laboratory of the University Hospital at Ann 
Arbor would indicate that these figures are too high, and the 
3.5 to 4.5 mm. would be more nearly correct. 

It has been established by Borrissow and Schutz that the 
amount of pepsin in one juice, as compared with another, is 
as the squares of the number of millimetres digested are to 
each other. The foregoing fundamental statements are gath- 
ered from Jung's abstracted translation of Pawlow's book, 
"The Work of the Digestive Glands" (Jour. A. M. A., May 
10, 1902), and is the basis of the experiments that follow. 

There are several ways of preparing and preserving the 
Mett tubes, the one employed by the writer is as follows : 
Thin-walled glass tubing having a calibre of 1.5 mm. is 
cleansed in distilled water and dried. It is then cut into 
lengths of about 10 cm., convenient for storage for use. These 
then are filled by suction with the white of a fresh egg. The 
egg-albumin must be free from air bubbles, one of the chief 
sources of annoyance and error being the presence of these 
air bubbles. In filling the tubes the endeavor is made to 
secure only the more fluid portion of the egg. This can be 
done readily by care and manipulation. As each tube is 
filled its ends are passed slowly through a white gas flame, 
thus forming small coagulated plugs, which serve temporarily 
to prevent the escape of albumin. When a sufficient number 
of these tubes are thus prepared they are placed in a basin 
of distilled water, supported on glass rods. The water is 
then heated to a temperature between 90° and 95° C, which 
is maintained for five minutes. Care is taken to keep an 
equable temperature throughout the basin. From here the 
tubes are transferred to a 66 per cent, watery solution of glyc- 



SHORT METHOD. 123 

erine, in which they are preserved. When it is wished to 
make a test a tube is selected, the glycerine washed therefrom, 
and about 10 mm. of one is snipped off, a sharp Stubb's file 
being employed for this purpose. This piece is thrown away 
and another about 18 mm. long is taken. In this way a por- 
tion is secured free from the action of glycerine, which has an 
inhibiting effect on the digestion of the egg. This small tube, 
placed in 3 or 4 c.c. of gastric juice is put into the incubator, 
and left for either ten or twenty-four hours. The digestion 
in twenty -four hours is proportionately more. For the rea- 
sons before stated ten hours is preferred, but usually the 
twenty-four-hour period is much more convenient and is 
therefore used. Frequently in the digested tubes two zones 
will be seen, one perfectly clear, from which the albumin has 
entirely disappeared, the other hazy or cloudy. In other 
tubes cone-shaped translucent plugs are formed. The expla- 
nation of this is not quite clear, since in the more perfect 
tubes the digestion is sharply defined, there being only the 
clear digested and solid or undigested zones. The results 
may be recorded as the number of millimetres, but for pur- 
poses of comparison these figures should be squared, this 
being the true index to the amount of pepsin in the sample. 

Nirenstein and Schiff have shown that the strength of one 
gastric juice, as compared to another, is as the squares of the 
number of millimetres digested, only in juices up to a cer- 
tain strength. Beyond a certain point the rule does not hold 
good. Furthermore, they have shown that the soluble 
chlorides and carbohydrates interfere. They have obviated 
these difficulties by diluting the gastric juice fifteen times, 
16:1, under which conditions the laws are correct. For 
practical purposes, however, the old way is sufficiently accu- 
rate. Jung 1 draws the following conclusions from his work 
with this method : 

(1) The normal values for pepsin digestion are, according 
to Mett\s method, 5.5 to 5.9 mm. 

(2) Subacidity and anacidity have lower values than normal 
or superacidity — i. e., 1.9 mm. average. 

1 Jour. Am. Med, Assoc, May 10, 1902. 



124 THE STOMACH. 

(3) Superacid ity, generally speaking, has high and highest 
values of pepsin, yet there are cases of unusually high HC1 
figures with disproportionately low pepsin values. 

(4) The diminution of pepsinogen does not run proportional 
with that of HC1. Even with a deficiency of HC1 the value 
of pepsin can be higher than that of mild subacidity. Com- 
parison average of Hammerschlag and Mett methods : 

Mett 5.5 mm. superacidity ; 1.9 mm. subacidity. 

Hammerschlag . . 6.0 " " 4.5 " " 

Hammerschlag's Method of Quantitative Estimation of 
Pepsin. — Three Esbach's tubes are employed (albuminime- 
ters). Tube A is filled to the mark U with a mixture of 10 c.c. 
of a 1 per cent, solution of serum-albumin in 0.4 per cent, 
hydrochloric acid, and 5 c.c. of filtered gastric juice. The 
second tube (B), which is the standard, is also filled to the 
mark U, but 0.5 gramme of pepsin is added to the serum 
solution instead of the gastric juice. The third tube (C) 
simply contains a mixture of the serum solution and 5 c.c. of 
water. Place in thermostat for one hour at temperature of 
37° C. Esbach's reagent is added to each tube to the mark 
R. After standing for twenty-four hours the amount of pre- 
cipitated albumin is read off, and the difference between that 
in A and C compared with that in B. 

Rennet and its Zymogen. — A few drops of the stomach fil- 
trate are added to 10 or 15 c.c. of milk in a test-tube, and 
placed in a thermostat at a temperature of 37° C. If the 
rennet is normal, the milk will be coagulated solid or with 
the separation of a small amount of whey in ten to fifteen 
minutes. If the curdling takes place more slowly, rennet is 
deficient. 

If the filtrate does not show hydrochloric acid, add a small 
amount of calcium chloride solution to the mixture. Rennet 
zymogen, if present, is then converted into active rennet and 
coagulates the milk. 

Tests for Proteids. — Examine for acid albumin or syn- 
tonin, albumin, albumose, and peptone. The customary tests 
for proteids are used. 



EXAMINATION OF STOMACH DURING FASTING. 125 

Acid albumin, if present, is precipitated by carefully neu- 
tralizing the filtrate with the deeinormal solution. An excess 
of either alkali or acid redissolves the precipitate. 

Albumin. — After removing syntonin by neutralizing and 
filtering, the filtrate may be tested for albumin by the various 
well-known tests, such as Heller's ring test, acetic acid and 
potassium ferrocyanide, etc. 

Albumose. — Precipitate the syntonin and albumin by boil- 
ing the unneutralized filtrate. Filter, and test filtrate for albu- 
mose as follows : 

Mix equal quantities of the cooled filtrate and a satu- 
rated solution of sodium chloride ; add a drop or two of acetic 
acid. A turbidity or precipitate in the cold, disappearing on 
heating and reappearing on cooling, indicates presence of 
albumose. The filtrate should also give the biuret reaction. 

Peptone. — Remove albumin, syntonin, and albumose as 
above indicated. The filtrate should be negative to the albu- 
min tests. If peptone be present, it should give the biuret 
reaction — a violet-red or purplish color on the addition of a 
drop or two of dilute copper sulphate solution. Tannin and 
some other substances also give this reaction. 

Carbohydrates. — Starch, erythrodextrin, sugar, and achroo- 
dextrin, may be present in the filtrate. 

Starch.— Dilute a small amount of Lugol's solution to a 
light-yellow color ; add a few drops of gastric filtrate. If 
unchanged starch is present, a blue color results ; if ertyhro- 
dextrin a deep brown or mahogany. 

For detecting sugar the customary tests are used, such as 
Fehling's, etc. 

EXAMINATION OF STOMACH CONTENTS DURING 

FASTING. 

This procedure is of value in demonstrating dilatation and 
diminished motor power of the stomach, or the presence of an 
obstruction at the pylorus. If food is found in the stomach 
which has fasted overnight (eight to twelve hours), it gives 
evidence of one or all of the above conditions. 



126 



THE STOMACH. 



The fasting stomach is also examined to learn whether there 
is an excessive secretion of gastric juice. It should be washed 
out the night before. Normally the fasting stomach contains 
from a few cubic centimetres up to 50 or 60 c.c. of juice. 
Above this amount indicates hypersecretion, so-called Reich- 
man's disease. This juice should be subjected to the same 
tests as the juice obtained after a test-meal. 

Fig. 35. 




Collective view of vomited matter. (Eye-piece III., objective 8 A, Reichert.) 

or, muscle-fibres ; 5, white blood-corpuscles ; c, c/, squamous epithelium ; c", columnar 
epithelium; d, starch-grains, mostly changed by the action of the digestive juices: 
e, fat-globules ; /, sarcinse ventriculi ; g, yeast-fungi ; h, forms resembling the comma 
bacillus found by v. Jaksch once in the vomit of intestinal obstruction ; i, various 
micro-organisms, such as bacilli and micrococci ; k, fat -needles, between them con- 
nective tissue derived from the food ; I, vegetable cells, (v. Jaksch.) 

Ordinary Meal. — In patients complaining of indigestion 
much can be learned by removing the ordinary meal and sub- 
jecting it to all of the above routine examinations. In fact, 
the writer believes that in many instances such a meal may 
prove much more valuable than the test-meals. 

The vomitus should also be subjected to the above examina- 
tions — macroscopical, microscopical, and chemical. 

In suspected cancer of the oesophagus with regurgitation 



EXAMINATION OF MOTOR rOWER OF STOMACH. 127 

chemical examination often throws much light on the case. If 
the various acids (free HC1 and combined HC1) and ferments 
are present, it indicates that the material vomited is from the 
stomach. If absent, it indicates that the material had not 
reached the stomach (stricture of oesophagus with dilatation) 
or that a condition of achylia gastrica is present. 

The reaction of the vomitus to litmus-paper is of no value. 

EXAMINATION OF MOTOR POWER OF THE STOMACH. 

This is one of the most important of stomach examinations, 
and the one most often neglected. 

The best method is by the use of the stomach- tube. The 
average meal should be passed on into the intestine in six or 
seven hours. At the expiration of this time after an ordinary 
meal the tube should be passed and the stomach washed out. 
Presence of food indicates deficiency in motor power. The 
usual method is to wash out the stomach in the morning, before 
breakfast, nothing having been eaten since 6 o'clock the even- 
ing before. 

In mild cases of diminished motor power food may be 
retained in the stomach from meal to meal during the day, 
being finally passed into the intestine during the long fast 
of the night, 

Another but much less satisfactory method consists in 
administering a gramme of salol in three or four capsules 
immediately after a meal. Salol is unchanged in the acid 
contents of the stomach, but as soon as it mixes with the 
alkaline contents of the intestine it is decomposed into phenol 
and salicylic acid. The latter is absorbed and excreted in 
the urine, where it may be recognized. The addition of 
a few drops of ferric chloride solution, in the presence of 
salicylic acid or its derivatives, gives a brown or violet color. 
The urine should be tested every half to one hour for this 
reaction, and again after twenty-four hours. Normally it 
appears in sixty to seventy-five minutes. The salol should 
be entirely excreted in twenty-four hours. A delayed appear- 
ance of the reaction indicates diminished motor power. Nega- 



128 THE STOMACH. 

tive examinations during the first twenty-four hours indicate 
pyloric stenosis. Too many factors are involved to make 
this a satisfactory test. Stomach contents must be acid, in- 
testinal contents alkaline, and the kidneys should be normal. 
Diminished motor power is present in many gastric condi- 
tions, such as cancer of the stomach, with stricture of the 
pylorus, benign stricture of the pylorus, dilatation, gastric 
atony, gastroptosis, chronic gastritis, etc. 

ABSORPTIVE POWER OF THE STOMACH. 

Test. — A capsule containing 0.2 gramme of potassium 
iodide (all traces being carefully removed from outside of the 
capsule) is given shortly before a meal. The saliva is now 
examined every two or three minutes with starch-paper for a 
trace of potassium iodide. Normally a violet color is obtained 
in six and a half to eleven minutes, a bluish tinge in from 
seven and a half to fifteen minutes. 

A delayed appearance of the reaction is observed in most 
diseases of the stomach, especially in dilatation and carci- 
noma, less so in chronic gastritis, variable in ulcer ; but abso- 
lute dependence can not be placed on this reaction, since it 
has been obtained in dilatation and chronic gastritis within 
the normal time limit. 

SIZE, SHAPE, AND POSITION OF THE STOMACH. 

A fairly accurate idea of these three points may be gained 
by distending the stomach with air by means of the stomach- 
tube and atomizer bulb. This is a satisfactory method in 
those who take the tube well. In others it is well to distend 
the stomach with carbonic acid gas generated in the following 
way : 6 grammes of tartaric acid dissolved in half a glassful of 
water are swallowed, and immediately followed by a solution 
of 7 grammes of sodium bicarbonate in half a glassful of water. 
The stomach is immediately distended, revealing its position, 
shape, and in a general way its size. It should never be dis- 
tended in those giving a history of ulcer or recent hemorrhage. 

The capacity of the stomach is determined by measuring 
the quantity of water which can be poured into it through 



ORGANIC ACID FERMENTATION. 129 

the tube without causing special distress. That of the normal 
stomach varies with the individual, measuring on an average 
from 1000 to 1500 c.c. Ewald considered 1700 c.c. abnor- 
mally large. The extremes may be placed at 800 c.c. and 
2000 c.c. for the adult. 

Classification of Digestive Conditions. 

Normal HC1 acidity =Euchlorhydria. 
Increased HC1 acidity =Hyperchlorhydria. 
Diminished HC1 acidity = Hypochlorhydria. 
Absent HC1 acidity = Achlorhydria. 

Normal pepsin = Eupepsia. 
Increased pepsin = Hyperpepsia. 
Diminished pepsin = Hypopepsia. 
Absent pepsin = Apepsia. 

Organic Acid Fermentation. 
Duration of Digestion. 

1. Normal length of time. 

2. Increased length of time. 

3. Diminished length of time. 

QUESTIONS. 

What are the objects of stomach examinations? 

Mention the reagents required in this work. 

Describe the test-meals commonly employed. 

What are the contraindications to the use of the stomach-tube? 

Describe the correct method of passing the tube. 

What means are employed in the removal of the stomach contents ? 

What points are considered in the macroscopical examination of the stomach 
contents ? 

What are the microscopical findings in normal and abnormal stomach con- 
tents ? 

What is Giinzberg's test for free hydrochloric acid f 

Describe Kelling's test for lactic acid. 

Describe in detail Topfer's method for the quantitative determination of 
the acidity of the gastric juice. 

Describe Mett's method of determining peptic digestion. 

What facts are learned by the examination of the stomach contents during 
fasting? 

What methods are used in determining the motor power of the stomach ? 

Describe the test for determining the absorptive power of the stomach. 

How are the size, shape, and position of the stomach determined ? 

Classify the digestive conditions. 

9— C. D. 



130 . THE FuECES. 

CHAPTER IX. 

THE F^CES. 

The faeces consist of undigested particles of food, intestinal 
mucus, unabsorbed intestinal secretions, epithelial cells, and 
bacteria. 

The number of stools per day varies with the individual. 
The average person has one formed stool a day, usually at a 
regular time. 

There are numerous exceptions to this rule, as many healthy 
persons have normally only one stool in two or three days, 
while others have two or three daily. So in deciding whether 
there is constipation or diarrhoea, it is necessary to learn the 
" stool habit " of the individual 

The amount of faeces varies with the diet. It is much 
larger with a carbohydrate than with a proteid diet, 60 to 
250 grammes being the extremes in health. 

The consistence of the faeces depends on the character of the 
food in health. With a vegetable diet (containing 80 to 85 per 
cent, of water) it is much softer than with a proteid diet 
(containing 60 to 65 per cent, of water). Normal stools are 
usually cylindrical and firm. A mushy stool, however, may 
be normal for some persons. When faeces remain long in the 
intestine the moisture is absorbed, and they are passed as 
round, hard, scybalous masses. 

Odor of Faeces. — The presence of skatol and indol, products 
of albuminous decomposition, is largely responsible for the 
obnoxious odor of faeces. 

Sulphuretted hydrogen, methane, and traces of phosphin 
add to the odor. 

Color of Faeces. — The color varies according to the food, 
pathological products present, and medicine ingested. The 
ordinary color varies from light to a blackish brown. Exclu- 
sive milk diet produces a light-yellow stool. Under normal 
conditions the color is never due to native biliary coloring- 
matter, but chiefly to the presence of hydrobilirubin. 



THE F^JCES. 131 

Starches tend to produce a yellow, chlorophyll a greenish 
color. In obstructive jaundice the stool is of an ash or light- 
gray color. 

Blood in the stool (unless fresh) always gives it a dark 
appearance, the so-called tarry stool ; this is due to the forma- 
tion of hsematin. Iron, manganese, and bismuth produce a 
dark-brown or black color, owing to the formation of the 
sulphides of those metals. The green color of calomel stools 
is probably due to the presence of biliverdin. Santonin, 
rhubarb, and senna produce a yellow color ; hsematoxylin a 
red color resembling that of blood. 

The chemical reaction of the faeces varies much, depending 
on the kind of fermentation present. In intestinal catarrh 
with acid fermentation it is acid ; with alkaline fermentation 
it is alkaline. 

Macroscopical Examination of Normal Faeces. — Un- 
digested particles of food, skins of various animal and vege- 
table foods, berries, seeds and stones, woody vegetable fibres, 
large pieces of connective tissue, undigested pieces of fruits, 
grains of corn, flakes of casein, etc., are all frequently seen. 

Foreign bodies of various sorts are sometimes swallowed, 
and passed in the stools. It is necessary to keep this in mind 
when dealing with children, the hysterical, and the insane. 

Small quantities of mucus may be found in health, and 
particles resembling sago grains may be present as a result 
of overindulgence in starchy food. 

Stools of Vegetarians. — The color of the stools of veg- 
etarians is light brown, rarely becoming black as in the case 
of meat eaters. If eggs are largely used, however, and taken 
without proper mastication, the stools may become dark from 
the decomposition of the albumin. The consistence depends 
on the quantity of fluids or fruit that is eaten. When fruit, 
fruit juices or sugars are eaten in large quantity the stools are 
soft, 

When, on the other hand, the diet consists largely of grains 
the stools are apt to be hard ; and if the diet consists chiefly 
of bread with a small quantity of fruit, and when the food is 
masticated with very great thoroughness, the stools are likely 



132 



THE FJZCES. 



to be small and very dry. When fats are taken freely the 
stools are light in color (Kellogg). 

Macroscopical Examination of Pathological Faeces. — 
Mucus, when present in large quantities, indicates a catarrh 
of the mucous membrane of the intestine. 

In mucous colitis large strips of mucus (sometimes in the 
form of molds of the intestine, resembling sausage skins) are 
passed in the stools. 

Usually, when the mucus is mixed with the faeces and 
appears in small bits, it comes from the small intestine ; but 
in dysentery it may be mixed with the thin stool and come 

Fig. 36. 



V 






s *mmm 




Cholesterin crystals. (Simon.) 

from the large intestine. When the hard faeces are covered 
with mucus, or when it appears in shreds, it is derived from 
the large intestine. The " rice-water " stool of cholera is so 
named because of the presence of bits of mucus resembling 
grains of rice. 

Gall-stones should be sought for in all suspected cases of 
cholelithiasis. The Boas sieve will be found very useful for 
this purpose. These stones vary from the size of a pea to 
that of a hen's egg. They may be soft and crumbling masses 
(intrahepatic calculi, made up chiefly of cholesterin, Fig. 36), 
or hard and many-faceted. 



THE FMCES. 133 

They are usually light in weight, and vary in color from 
pale yellow to brown and green, or have a mottled appear- 
ance, and change color on exposure to air. 

Following the administration of olive oil, lumps of soap 
may form in the intestine and be mistaken for gall-stones. 

Blood. — When bright red in color, it usually comes from 
the rectum (haemorrhoids, fissures, etc.) or some part of the 
large intestine. However, if a large haemorrhage takes place 
in the small intestine (as in typhoid fever), the blood may 
pass quickly through the bowel and appear unaltered in the 
stool. Blood coming from the stomach and small intestine 
is usually altered by the juices of these organs and has a 
black color, the so-called " tarry " stool. 

Pus may appear in the stool in an unmixed state when 
abscess cavities rupture into and discharge through the 
bowels. It is often mixed with mucus or blood when derived 
from ulcerative conditions, as in dysentery, tuberculosis, etc. 
It may coat the stool or be mixed with it. 

Fat. — A small amount of fat is present in the normal stool. 
In diseases of the pancreas, jaundice, and diarrhoea it is 
present in unusually large amounts, giving the stool a greasy 
or clay-like appearance. 

Microscopical Examination of Normal Faeces. — Vegeta- 
ble cells, starch-granules, muscle-fibres, elastic tissue, con- 
nective tissue of w T hite fibrous variety, fat-globules, and 
flakes of casein are to be found. 

Under normal conditions muscle-fibres are not numerous 
unless unusually large quantities of meat have been eaten. 
Starch-granules if in excess — except in young children — in- 
dicate a pathological condition of the gastro-intestinal tract. 
They are easily recognized by the blue color they assume 
after running a few drops of LugoPs solution under the cover- 
glass preparation. 

Fat may occur in droplets or in the form of needle-like 
crystals or highly refractive polygonal masses of a yellowish 
or reddish-yellow color. 

Numerous bacteria are present in normal faeces (Fig. 37). 

Method of Obtaining Specimen. — Probably the most im- 



134 



THE FJECES. 



portant practical point connected with the microscopical 
examination of the faeces is the proper method of obtaining 
the stool. It should be passed into a warm receptacle, and 
the examination made as soon afterward as possible. This is 
essential when examining for Amoeba coli or trichomonades, 
since the diagnosis is rendered certain only by the detection 
of the characteristic movements of these organisms, which 
cease as soon as the faeces become cold. The amoeba may be 
kept active by the use of a warm stage. A good method of 
obtaining a specimen for examination at one's own conve- 

Fig. 37. 




Collective view of the faeces. (Eye-piece III., objective 8 A, Reichert) : a, muscle- 
fibres ; b, connective tissue ; c, epithelium ; d, white blood-corpuscles ; e, spiral cells ; 
/, i, various vegetable cells ; A% triple phosphate crystals in a mass of various micro- 
organisms ; I, diatoms, (v. Jaksch.) 

nience is by the introduction of a rectal tube. In the various 
diarrhoeas a small amount of faeces will be brought away by 
the tube. In using the rectal speculum a quantity of the 
desired material can usually be obtained. As a routine 
measure, in order to secure a satisfactory stool for examina- 
tion, an ounce of Carlsbad salt should be given before break- 
fast. Several liquid stools usually result. If the material 
is tenacious, such as the bloody mucus in cases of amoebic 
dysentery or the muco-pus of tuberculosis, it can be transferred 
to a glass slide with the teasing-needle ; if watery, it can be 



THE F^CES. 135 

drawn up into a small glass pipette by capillary attraction 
and a drop or two transferred to the slide and a cover-glass 
placed over it. This is examined with a high, dry objective. 

For staining, spreads should be made and fixed as with 
sputum preparations. 

Morphological Elements derived from the Alimentary 
Canal. 

1. Epithelial Cells. — The cylindrical and goblet cells are 
almost always so altered in the normal faeces that it is difficult 
to recognize them. 

Pavement epithelial cells, when present, come from the 
anal orifice. 

2. Leukocytes are almost never found in normal stools. 

3. Red blood-corpuscles may occasionally be present in very 
small numbers. 

4. Structureless granules in large numbers may be seen in 
every stool. 

5. Necrotic tissue and pieces of new growth may be present 
in the faeces. 

6. Crystals. — A large number of crystals — of almost no diag- 
nostic importance — are found ; these are needle-like crystals 
of free fatty acids (Fig. 38). Calcium and magnesium salts, 
neutral calcium phosphate and ammonio-magnesium phos- 
phate. Calcium oxalate crystals occur in abundance follow- 
ing ingestion of certain vegetables, as sorrel and spinach. 
Calcium carbonate and sulphate, and (in children) lactate of 
calcium are rare. Hsematoidin crystals are never found in 
normal stools. Charcot-Leyden crystals are found under cer- 
tain pathological conditions, and are supposed to indicate the 
presence of intestinal parasites. 

Vegetable and Animal Parasites. — Vegetable parasites are 
always present in enormous numbers. It is not yet known 
what relation they bear to the process of digestion. It has 
been proved that they are not entirely essential. Fungi are 
rarely found. Schizomycetes belong to the normal constituents. 

About 97 per cent, of bacteria are derived from the ingested 
food and 3 per cent, from the saliva. Most of these are 
non-pathogenic, but unJer suitable conditions a small per- 



136 



THE FAECES. 



centage develop pathogenic properties. There are two large 
classes found in normal stools : 

Class I. are stained a yellow or yellowish-brown with iodo- 
potassic iodide. 

Class II. are colored blue or violet. 

Routine bacteriological examinations of the faeces are 
of little practical value because of the enormous number of 
bacteria of all kinds that occur in the feces and the almost 



Fig. 38. 




Fatty crystals obtained from the feces. (Simon.) 

insurmountable difficulty of isolating them, and because, as a 
rule, there are easier methods of recognizing disease. 

In acute infectious tropical dysentery a specific bacillus, 
that of Shiga and Flexner, or that of Strong, is found in 
the intestinal discharges. 

In typhoid fever the Eberth bacillus is present in the 
stools, but it is difficult to isolate because of its close resem- 
blance to numerous members of the colon group. The spe- 
cific organism of Asiatic cholera is present in the feces in 
that disease. 

Tubercle Bacillus. — The examination of the stools for 



THE FJSCES. 137 

tubercle bacilli, or of discharges for pus obtained during rectal 
examination, is a very important procedure in establishing or 
excluding the diagnosis of intestinal tuberculosis. It must 
be remembered that the stools may be contaminated by 
swallowed sputum. 

Method of Search for the Tubercle Bacilli. — If pus is found, 
cover-glass preparations should be made, fixed, and stained, 
as in the sputum examination. To find tubercle bacilli in 
feces, dilute the stool with 10 volumes of water in a wide- 
mouthed bottle of 200 c.c. capacity. Mix thoroughly and 
let stand for twenty-four hours. The tubercle bacilli will be 
found in the narrow layer between the thin liquid and the 
more solid sediment. With a pipette, some of this material 
is drawn off and spreads made from it. 

The feces may be carefully inspected in the receptacle, and 
suspected bits of mucus or muco-pus removed with teasing- 
needles, and spread upon cover-slips and examined in the 
routine way. 

For method of differentiating from smegma bacilli, see 
chapter on Urine. 

Animal Parasites. — The adult form and the ova are found 
in the human intestine and feces. 

They belong to the classes of : 
I. Protozoa. 
II. Vermes or worms. 

III. Insects. 

Only a few are common to man in the United States. Spe- 
cial mention is made of these alone. The possibility of con- 
tamination of the stools must always be kept in mind. 

I. Protozoa. — Amoeba coli is the only protozoon of patho- 
logical importance. Its etiological relation to amoebic dysen- 
tery has been proved by many observers. It is, of course, 
rarely found in the temperate zone, and is of more interest to 
tropical medicine. However, it has been found in the north- 
ern part of the United States, and every case of dysentery 
should be examined for this parasite. It is found in abscesses 
of the liver complicating tropical dysentery. 

The Amoeba coli is found especially in the mucopurulent or 



138 



THE FMCES. 



gelatinous masses of the faeces. These organisms may be so 
numerous as to fill completely the field under the microscope. 
They vary in size from 12 to 35 jut in diameter. They consist 
of a clear outer zone (the ectosarc) and a granular inner zone 
(endosarc), a nucleus, and one or two vacuoles. They are 
easily recognized during their active stage by their peculiar 
amoeboid movements, which greatly alter their shape. Pseu- 
dopodia are thrust out from the periphery and the remainder 
of the cell flows into it. When cold, it is difficult to recognize 
them, and they are likely to be mistaken for swollen, altered, 

Fig. 39. 




Amoeba coli. (Hallopeau.) 

granular epithelial cells (Fig. 39). They are well stained by 
Wright's method. 

Trichomonas and Cejxomonas intestinalis are frequently 
found in diarrhoeal stools, but seem to have no causal rela- 
tion. They are pear- or oval-shaped bodies possessing fla- 
gella. The trichomonas is the larger, and, in addition to the 
flagella, shows an undulating membrane (Fig. 40). 

Other protozoa found in the intestine are coccidia, cerco- 
monas, Megastoma entericum, and Balantidium coli. 

II. [Vermes Worms). — Cestodes (Tapeworms). — These are 
recognized in the macroscopical examination of the feces by 



THE F^CES. 



139 



discovering the segments (proglottides), either singly or a 
number of them joined together. The important part, and 
that most difficult of recognition, is the head. It is joined to 
the slender neck — and its variety can be learned by micro- 
scopical examination under a low power. 

Tcenia saginata is the most common tapeworm in Europe 

Fig. 40. 




Trichomonas intestinalis : a, a f , e, trichomonas of the urine, after Marchand ; 
b. Trichomonas vaginalis, after Donne ; b f , same, after Scanzoni and Kolliker ; d, 
Trichomonas intestinalis, after Piccardi ; e, ef ', e", same, amoeboid forms ; /, /', 
trichomonas of the urine, after Dock. 

and North America. It is the beef tapeworm, and is recog- 
nized by the fact that its head is unarmed. 

The head is surrounded by four pigmented suckers, each of 
which is encircled by a dark ring* Each segment contains 
male and female generative organs. The uterus occupies the 
centre, and has numerous clichotomoug branches, about twenty 



140 



THE FJECES. 



Fig. 41. 






Taenia saginata : a, natural size ; 6, head much enlarged ; c, ova much enlarged. 

(Simon.) 



THE FJSCES. 



141 



on a side (Fig. 41). The ova are elliptical, brown, and usually 
enclosed in a vitelline membrane. 

Tcenia Solium.-*-A pork tapeworm, rarely found in the 
United States, but common in Asia and Africa. It is usually 

Fig. 42. 




Head of Taenia solium ; X 45. (Leuckart.) 

much shorter than the saginata, and its distinguishing charac- 
teristic is its armed head. In addition to the four pigmented 
suckers there is a rostellum at the tip, furnished with twenty- 
four to twenty-six hooklets arranged in a double row. The 
mature segments differ from those of the saginata in having a 
uterus with only five to seven branches (Fig. 42). 

The ova are round, of a brownish color, and surrounded 

Fig. 43. 




Bothriocephalus latus. 



with a thick, radially striated membrane. The hooklets of the 
embryos can usually be found in their interiors. 

Bothriocephalus Latus, — This worm is found much more 
rarely than the other two in this country. It is very large, 



142 



THE FMCES. 



being 5 to 9 m. in length. Its head is shaped like a bean, 
and on its flat surface are two distinct grooves which probably 
act as suckers. 

The segments are almost square. The genital apparatus 
opens in the median line. The uterus presents four to six 



Fig. 44. 




Ascaris lumbricoides. (Eye-piece I., ob- 
jective 8 A, Reichert) : a, worm, half natu- 
ral size ; b, head slightly magnified ; c, eggs, 
(v. Jaksch.) 



Fig. 45. 




Oxyuris vermicularis : a, head ; 
6, male ; c, female ; d, eggs. (v. 
Jaksch.) 



convolutions on each side. In water they have a rosette-like 
appearance (Fig. 43). 

The ova are oval, enclosed in brown envelopes, at the 
anterior ends of which a lid can be recognized. It is found 
in Europe and Japan, and is of marked pathological interest 
because it produces a severe form of ancemia. 

Nematodes (filiform, resembling a thread) differ from ces- 



THE FMCES. 



143 



todes in having the sex distinct. The female is always larger 
than the male. The most important of these are : 

Ascaris lumbricoides, Oxyuris vermicularis, Uncinaria duo- 
denalis (very important variety) (Anchylostoma duodenale), 
and Trichinella spiralis. 

Ascaris lumbricoides is the most common human parasite, 
and is found chiefly in children. The female is 7 to 12 
inches long, the male from 4 to 8 inches. It is cylindrical, 
pointed at both ends ; four longitudinal bands can be seen, 



Fig. 46. 



1? a 




Anchylostomum duodenale : a, male, natural size ; b, female, natural size ; c, 
male, magnified; d, female, magnified; e, head (eye-piece II., objective C, Zeiss) ; 
/, eggs. (v. Jaksch.) 

and it is striated transversely. It may be reddish in color or 
yellowish brown. Its head is trilobed (Fig. 44). 

The ova may be found in large numbers in the feces. They 
are small, oval, 60 to 75 mm. in size, brownish red, with a 
thick covering. 

Oxyuris Vermicularis.- — This is a small round worm ; the 
female measures 10 mm., the male 4 mm. in length. They 
may be present in the lower bowel and faeces, and look like 
bits of thread (Fig. 45). 



144 



THE FJECES. 



The ova are about 50 by 24 // in size, coarsely granular, 
and surrounded by a double-contoured envelope. 

Uncinaria Duodenalis : (syn., Anchylostoma duodenale (Fig. 
46). The great importance of this parasite as a cause of 
certain forms of anaemia has been properly emphasized dur- 
ing the past few years. It is a blood-sucking parasite, and 
is one of the most dangerous met with in the human being. 
It has a wide distribution, being found in Italy, Germany, 

Fig. 47. 




Eggs of Uncinaria amerieana in different stages of development. (Personal obser- 
vation.) Magnified about 300. (Simon.) 

Switzerland, Belgium, and Egypt. C. N. Stiles has recently 
shown that the hook-worm, found in the United States and 
West Indies, is a distinct species. He has denominated it 
the Uncinaria amerieana. This investigator has demon- 
strated that it is a very common parasite in the sandy regions 
of the South. Infection with it is very common among the 
poorer classes of this region, probably as a result of the habit 
of dirt-eating. The stools of all cases of severe aiuemia 



THE FMCES. 



145 



should be carefully examined for the eggs of this parasite. 

The adult worm is almost never found in the faeces (Fig. 46). 

The parasite is fairly common in dogs, cattle, and sheep. 



Fig. 48. 










Trichina spiralis in muscle. (Simon.) 



The female is 10 to 18 mm. long ; male 6 to 12 mm., with an 
expanded copulatory pouch and slender penile organ at its 
posterior extremity. The head is turned dorsally and has a 
10— C, D, 



146 THE FJECES. 

hollowed mouth armed with six booklets. The ova are 
abundant in the feces, are elliptical (30 by 50 //), and have a 
thin, colorless, vitelline envelope, enclosing varying numbers 
of rapidly dividing cells. These segmenting bodies rapidly 
develop outside of the human body, so that after twenty-four 
to forty-eight hours embryos may be found in the same feces 
in which the eggs were observed, or fully developed ova may 
be found after allowing the feces to stand for only a few 
hours. (Fig. 47.) 

Examination of the Faeces in Uncinariasis. — There are 
two methods, the microscopical and the gross. 

Microscopical Examination. — Take a small amount of the 
feces, preferably from near the surface, spread this out in a 
drop of water on a microscopic slide and cover the prepara- 
tion with a cover-slip. Examine under the low dry objective, 
with not too strong illumination, or for closer study with the 
high dry objective. Do not mistake the egg of the unci- 
naria for that of the Ascaris lumbricoides, which has a thick, 
gelatinous, often mammillated, covering, and an unsegmented 
protoplasm, or the egg of the Oxyuris vermicularis, which 
has a thin, asymmetrical shell (one side being almost straight) 
and containing an embryo, or for the egg of the whip-worm 
(Trichuris trichiura, more commonly known as Trichocephalus 
dispar), which possesses a smooth, thick shell, apparently per- 
forated at each pole, and an unsegmented protoplasm (Stiles). 

Gross Examination. — Give a small dose of thymol, 10 to 
15 grains, followed in two hours by oil, and collect all of the 
stools passed. Wash the stools thoroughly several times in 
a bucket, and examine the sediment for worms about half 
an inch long, about as thick as a hair-pin, and with one end 
curved back to form a hook (Stiles). 

Trichinella Spiralis. — The adult forms of the trichina occur 
in the intestine. They are 1.5 to 4 mm. long, and may be 
found in the stools in trichiniasis. The larval forms can 
be demonstrated by pressing a small piece of favorable muscle- 
fibre between slides, and examining under the microscope with 
a low power (Fig. 48). 

Chemistry of the Faeces. — The clinician seldom finds the 



SPUTUM. 147 

chemical analysis of the faeces of any practical value ; hence 
the reader is referred to the larger text-books for its con- 
sideration. 

QUESTIONS. 

What factors are responsible for the consistence, odor, and color of faeces ? 

What are the macroscopical findings in normal and abnormal faeces ? 

What are the microscopical findings in normal faeces ? 

Name the varieties of parasites found in faeces. 

Mention the important vegetable parasites found in faeces. 

Classify the animal parasites found in faeces. 

Describe the Amoeba coli. 

What is the difference between a cestode and a nematode ? 

Mention the important cestodes and nematodes. 

Describe the Uncinaria duodenalis and its ova. 

Describe the methods of examining the faeces in uncinariasis. 

How are the larval forms of Trichinella spiralis demonstrated ? 



CHAPTER X. 

SPUTUM. 

GENERAL CONSIDERATIONS. 

Apparatus for examination of sputum includes — 

Glass teasing-needles made from glass rods. 

Platinum loop. 

Glass plate, 5 inches square. 

Kronig's sputum plate or a soup plate with bowl painted 
black. 

Slides. 

Cover-slips. 

Stains and reagents for examination of sputum — 

Carbol-fuchsin. 

Loffler's methylene-blue. 

Gabbets stain. 

Reagents for Gram's stain. 

Eosin, same as in blood w 7 ork. 

Nitric acid, about 30 per cent. 

The term sputum means that material which is brought up 
from the pharynx and respiratory tract by the acts of cough- 



148 SPUTUM. 

ing, hawking, and at times vomiting. It is usually asso- 
ciated with diseases of the pharyngo-respiratory mucous mem- 
branes, and its examination is often of great value in throw- 
ing light upon diseases of the respiratory and neighboring 
organs. 

General Remarks. — Sputum examination has become one 
of the most important and useful of laboratory diagnostic 
measures. To be of the largest value, it must be combined 
with a proper physical examination. In most instances the 
examination of the sputum furnishes only an etiological, not 
a pathological, diagnosis. At times it is possible to make a 
diagnosis of beginning tuberculosis from the physical signs 
when tubercle bacilli can not be found in the sputum. On 
the other hand, it frequently happens that the physical signs 
are very indefinite, possibly indicating a slight bronchitis ; in 
such cases tubercle bacilli are often demonstrated and the 
diagnosis clinched. 

Failure to find the bacilli may be due to the fact that the 
sputum is chiefly from the throat and contains none of the 
suspected bacteria. In a great many cases, especially when the 
bacilli are scarce, it is due to faulty technique. One frequently 
sees sputum examined in the following imperfect manner : A 
platinum loop is dipped at random into the sputum cup and 
a small amount of sputum withdrawn, placed upon a cover- 
slip, spread, fixed, and stained, with negative results. Such a 
method is very faulty, and can not be depended on except in 
advanced cases of tuberculosis, when the entire sputum is 
filled with bacilli. 

Correct Method of Obtaining Sputum. — The patient 
should be told to clean the mouth thoroughly and expecto- 
rate into a clean sputum cup or wide-mouthed glass bottle, in 
order to avoid contamination with food, since food particles 
roughly resemble the opaque bits which are rich in tubercle 
bacilli. Throat sputum, except in cases of laryngeal tuber- 
culosis, seldom shows anything of importance. To secure 
sputum from those with suspicious signs but scant expectora- 
tion, it is sometimes useful to administer potassium iodide in 
doses of 3 grains every three or four hours. 



GENERAL CONSIDERATIONS. 



149 



Correct Method of Examining Sputum. — The sputum 
should be poured upon a glass plate. This may be an ordinary 
window pane or a cleaned photograph plate. By means of 
two sharp-pointed glass teasing-needles the sputum is torn 
apart and carefully inspected. A second method consists in 
the use of a glass slide (Fig. 49). The sputum is pressed out 
between plate and slide ; about an inch of the slide extends 
beyond the plate and is used as a handle. If present, the 
suspicious opaque bits can be readily seen. The slide is 
moved about so that fresh portions of sputum are examined 
successively. 

When suspicious particles are found by these macroscopical 




Author's sputum slide. 

methods, they are either transferred immediately to cover- 
slips and spreads made or, better, the plate is transferred to 
the microscope, and the particles examined in situ with a low- 
power dry lens. By this means it can be immediately de- 
termined whether it is a bit of food, elastic tissue, or a col- 
lection of pus. The slide can now be slipped off and the bit 
transferred to a cover-slip if staining procedures are indicated. 
Methods of Spreading Sputum. — 1. Transfer the sus- 
pected bit of sputum to a cover-glass, place upon it another 
cover-glass, press down with forceps until the material i§ 
spread out in a thin layer, and slide them apart, 



150 SPUTUM. 

2. The material may be spread in a thin layer with the 
teasing-needle or the platinum loop. 

The cover-slips are dried in the air or held in the fingers 
above a flame, then fixed by passing them several times 
slowly through the flame of a Bunsen burner or alcohol 
lamp. 

Sputum Examination. — The examinations of the sputum 
which are of value to the clinician are macroscopical and 
microscopical. 

Macroscopically the following points should be noted : 

(1) Quantity in twenty-four hours or during a certain 
stated period 



( (a) consistence. 

1 (h\ 



(2) Character-^ (b) color. 
( (c) odor. 

The amount of sputum varies much with the disease. In 
some conditions only a few cubic centimetres are raised in 
twenty-four hours, in others 1000 c.c. and more. In incipient 
tuberculosis, early stages of acute bronchitis, and dry pleurisy, 
and some cases of croupous pneumonia the cough may be fre- 
quent, with little or no expectoration. On the other hand, in 
some cases of chronic bronchitis, advanced tuberculosis with 
cavities, hemorrhage from the lungs, pulmonary oedema, bron- 
chiectasis, and perforations into the lungs of pus from the 
thorax or abdomen, there is a large amount of sputum. 

In bronchiectasis large quantities of mucopurulent sputum 
may be raised in a short time, with change of position, espe- 
cially op rising in the morning. 

Consistence of Sputum. — The consistence corresponds in a 
general way to the amount ; it may vary from a watery to an 
extremely tenacious sputum. Whether mucin or nuclein 
derivatives are the cause of the tenacity is not thoroughly 
understood. 

In oedema of the lungs the sputum is liquid and resembles 
blood-serum, and is covered by a frothy surface layer. When 
the sputum is mostly pus, as in pulmonary gangrene, pulmo- 
nary abscess, putrid bronchitis, and following the perforation 
of an empyema or subdiaphragmatic abscess into the lungs, it 



GENERAL CONSIDERATIONS. 151 

is quite liquid. In croupous pneumonia the sputum is so 
tenacious that the cup containing it may be inverted with- 
out losing a drop, provided there is not an associated bron- 
chitis. 

This is also the case following an attack of bronchial 
asthma and in the beginning stages of acute bronchitis. 

Color of Sputum. — The color may vary from colorless 
mucoid to the dark-brown sputum containing altered blood. 
It may be gray, yellow, green, red, or brown. Admixture 
with fresh blood gives the red color, while admixture with pus 
(depending on the number of leukocytes) gives a color varying 
from gray to green. Green sputum may be due to admixture 
with bile, as in the perforation of a liver abscess into the lung, 
jaundice, and pneumonia accompanied by jaundice. 

The sputum in amoebic abscess of the liver which has per- 
forated the lung has a color resembling anchovy sauce — red- 
dish-brown, of a brick-dust color — due to blood-pigments and 
corpuscles. 

Red sputum, varying in intensity with the amount of blood 
present, is found in pneumonia, tuberculosis, heart disease, 
gangrene and abscess of the lungs. In pneumonia the spu- 
tum gradually changes from a bright-red color, due to un- 
changed blood, to a rusty or orange shade. In low types of 
the disease it resembles prune juice. 

Prune-juice sputum (dark mucoid) is present in a large per- 
centage of cases of cancer of the lungs. 

Greenish-yellow sputum in coin-like lumps is found in 
influenza (PfeifFer). 

In anthracosis the sputum may be very dark in color, 
so-called " black spit." 

Odor of Sputum. — Sputum is usually odorless, but at times, 
as in foetid bronchitis and pulmonary gangrene, the stench is 
most obnoxious. 

In bronchiectasis, perforating empyema, and ulcerative proc- 
esses the odor is sweetish. 

In perforating empyema an odor resembling old cheese is 
sometimes present, 



152 SPUTUM. 

Varieties of Sputum. — 

f Mucoid. 

Homogeneous \ P^ulent. 
oerous. 
(^Sanguineous, 
f Mucopurulent. 

JV1 u o o se t*ou s 
Heterogeneous -l a 

j berosanguineous. 

(^ Sanguinomucopurulent. 

Sputum crudum is an example of pure mucoid sputum, and 
is seen in the first stages of bronchitis. 

Nummular sputum is made up of roundish, coin-like disks, 
which sink in water. It is found in the second and third 
stages of phthisis. 

Sputum globosum consists of fairly dense, round, grayish- 
white masses, secreted in old cavities. 

Cheesy particles, varying in size from that of a millet-seed 
to that of a pea, are seen in cases of tuberculosis. They are 
usually rich in tubercle bacilli and elastic tissue. It is im- 
portant to search for such particles in the macroscopical ex- 
amination of sputum. 

Caseous masses which form in the crypts of tonsillar tissue 
are very common and frequently cause much unnecessary 
worry. They are coughed up or brought up by clearing the 
throat. Their microscopical examination is negative. They 
have a very foul stench, due to fatty acids. 

Macroscopical examination of sputum by means of teas- 
ing-needles, glass plate and slide is of great value in facilitat- 
ing the microscopical examination. 

Opaque particles may contain elastic tissue or tubercle bacilli. 

Fibrinous casts may appear as masses of a white color ; 
they are often yellowish brown or reddish yellow, owing to 
the presence of blood coloring-matter. They are found in 
fibrinous bronchitis, pneumonia (either before or after resolu- 
tion has taken place), and in cases of diphtheria where the dis- 
ease has extended into the finer ramifications of the bronchi. 
The suspected bits should be transferred from the glass plate 
or Kronig's sputum plate, and shaken out in water in order to 



GENERAL CONSIDERATIONS. 



153 



unravel them. These casts may vary from 12 cm. in length 
by several millimetres in thickness, to very small fragments 
0.5 to 3 cm. in length. Those found in pneumonia are small ; 
those in fibrinous bronchitis come from the smaller and 
medium-sized bronchi. 

These casts branch dichotomously and contain a cavity in 

Fig. 50. 




Fibrinous coagulum from a case of croupous pneumonia. (Bizzozero.) 

their larger portion, while the finer branches appear to be 
solid (Fig. 50). 

Curschmann's spirals occur in bronchial asthma, also in 
chronic bronchitis and even in pneumonia. Macroscopically 
they appear as thick, yellowish-white masses, which show a 
spirally twisted appearance, 



154 SPUTUM. 

Microscopically with the low power they are seen to consist 
of a spirally twisted network of extremely delicate fibrils, which 
is wound around a clear, colorless central thread. In this 
mass are found epithelial cells and leukocytes which are 
mainly of the eosinophile type. Not all spirals are perfect ; 
the central thread may be absent or the spiral arrangement 
may be imperfect. They vary in length from 1 to 1.5 cm. 
Their presence usually indicates a desquamative catarrh of the 
bronchi and alveoli (Fig. 51). 

Echinococcus membranes, concretions, and foreign bodies 
are rarely found. 

Ftg. 51. 







A Curschmann spiral from a case of true bronchial asthma. (Simon.) 

Microscopical examination of sputum consists in the use 
of a low dry lens with the glass plate and slide, and of a 
high dry lens with cover-glass and slide, and of an oil immer- 
sion with stained preparations. 

The objects of chief interest and diagnostic value are : 

(1) Elastic tissue. 

(2) Parasites. 

(3) Red blood-cells. 
Of less value are : 

(1) Leukocytes. 

(2) Epithelial cells. 

(3) Crystals. 

(4) Food particles, 



GENERAL CONSIDERATIONS. 155 

The examination should begin with the employment of the 
glass plate under a low-power lens. Attention is directed 
especially to the small opaque bits. 

Examination for Elastic Tissue. — A portion of sputum is 
placed upon a glass plate about 5 inches square, a size con- 
venient for handling on the stage of the microscope. With a 
slide for a spatula the sputum is pressed out into thin layers, 
and all suspicious bits examined. Elastic tissue-fibres have 
the following appearance under the low power of the micro- 
scope ; they are very slender threads of varying lengths, curl- 

Fig. 52. 




Elastic fibres in the sputum. (Eye-piece III., objective 8 A, Keichert.) (v. Jaksch.) 

ing and branching somewhat at their ends. They refract 
light in such a way as to give them the appearance of having 
a double wavy contour with a colorless centre. Occasionally 
they show an alveolar arrangement, making plain their origin 
(Fig. 52). 

Macroscopically, particles of food, masses of epithelium, 
and debris are most often mistaken for these suspicious bits 
which contain elastic fibres. 

Microscopically, the beginner frequently mistakes vegeta- 
ble fibres, such as lint from a towel, etc., and masses of lepto- 
thrix for elastic tissue, 



156 SPUTUM. 

The more slender fibre with its double contour and curl- 
ing, branching ends distinguishes the elastic fibre (Fig. 52). 

Whenever elastic tissue is found, it is certain that a 
destructive process is going on in the respiratory tract. It is 
especially important when associated with tubercle bacilli. It 
is most frequently found in tuberculosis, but may also be present 
in abscess of the lung, bronchiectasis, and occasionally in pneu- 
monia. In gangrene of the lung, elastic tissue usually is not 
found (perhaps it is destroyed by a ferment). 

Vegetable parasites found in sputum are : tubercle bacilli ; 
Diplococcus pneumoniae ; bacillus of influenza ; streptococci 
and staphylococci; Leptothrix buccalis; Oidium albicans; 
Aspergillus fumigatus ; Mucor corymbifer, etc. 

Tubercle Bacillus. — By far the most important sputum ex- 
amination is that for tubercle bacilli. After selecting the 
suspicious bits by macroscopical examination they are trans- 
ferred to cover-slips or slides, and spreads made as directed. 
These are fixed by passing through a flame several times, 
specimen side up, and are then ready to be stained. If the 
specimen is spread upon a slide, forceps are unnecessary, and 
cover-slips may be dispensed with, unless permanent speci- 
mens are desired. 

Methods of Staining. — The following solutions are re- 
quired : 

(1) Carbol-fuchsin. 

(2) 25 per cent, nitric acid. 

(3) L5ffler ? s methylene-blue. 

The cover-glass, held with forceps, is covered with a few 
drops of carbol-fuchsin, placed over a flame till it steams, 
then moved aside, and returned to the flame several times. 

The stain is washed off in water, and the specimen dipped 
into the nitric acid solution for a few seconds till pretty 
thoroughly decolorized, only a faint pink tint remaining. 

The specimen is again washed in water till it is certain 
that all traces of nitric acid are removed. It is then covered 
with a few drops of the methylene-blue solution for one-half 
to one minute. This is washed off with water and the speci- 
men dried between filter-paper and mounted in Canada 



GENERAL CONSIDERATIONS. 157 

balsam, and examined with the oil immersion ; or it may be 
examined in water instead of Canada balsam. 

The bacilli appear as red rods on a blue background, 
measuring from 3 to 4 p. in length by 0.3 to 0.5 ju in 
breadth. They may appear homogeneous, or as made up of 
small red beads with unstained spaces between ; they may be 
straight or curved, and occasionally branched. 

The beginner often mistakes the edges of cells or particles 
of dirt, which retain the red color, for these bacilli. 

Very little dependence can be placed upon the relation 
between the number of bacilli and the severity of the disease. 
In some incipient cases many bacilli are found in the mucoid 
sputum ; while, on the other hand, in some advanced cases 
and in acute miliary tuberculosis the bacilli are scarce. 

As a rule, however, the severity of the disease corresponds 
in a general way with the number of bacilli. * 

Gabbet's Method. — The fixed spreads are stained with 
carbol-fuchsin as in the above ; washed in water, and covered 
with Gabbet's solution, which consists of 75 parts of water, 
25 of sulphuric acid, and 2 of methylene-blue. This is 
allowed to remain for from fifteen to sixty seconds, until by 
washing in water the red color is seen to have disappeared 
and been replaced by the blue. The preparation is dried be- 
tween filter-paper and mounted in Canada balsam. 

If the physical signs are suspicious and the tubercle bacilli 
have not been found, it is wise to resort to the following de- 
vices to increase the chance of finding them : 

(1) Nuttal has demonstrated that these bacilli will multiply 
in the sputum itself at a certain temperature. It is w T ell then 
to place the specimen of sputum in the incubator for twenty- 
four to forty-eight hours and then examine it. 

(2) The use of the centrifugal machine also increases the 
chance of finding the bacilli. The following procedure may 
be employed : About 100 c.c. of sputum are boiled with 
double the amount of water, to which from 6 to 8 drops of a 
10 per cent, solution of sodium hydrate have been added, 
until a homogeneous solution has been attained, water being 
added from time to time to allow for evaporation. This is 



158 SPUTUM. 

then centrif ugated or set aside for twenty-four to forty-eight 
hours and the bottom portions examined for tubercle bacilli 
and elastic tissue. 

The only organisms likely to be mistaken for the tubercle 
bacillus are the bacillus of leprosy and the smegma bacillus. 
All three organisms are characterized by the great tenacity 
with which they retain acid stains and the great difficulty 
with which they take up basic dyes. The latter two organ- 
isms are, however, almost never found in the sputum. 

In the examination of urine and faeces, however, it is nec- 
essary to exclude smegma bacilli by the use of Pappenheim's 
stain or decolorization in alcohol. 

Diplococcus Pneumoniae. — In the great majority of cases of 
lobar pneumonia this organism is the etiological agent, and 
can be found in the sputum. It is a rod-shaped diplococcus 
surrounded by a characteristic capsule, which serves to dis- 
tinguish it from other cocci. 

Welsh's Method of Demonstrating the Capsule. — Spread and 
dried cover-glass preparations are treated first with glacial 
acetic acid, which is allowed to drain oif, and is replaced 
(without washing in water) with anilin gentian-violet solu- 
tion. The stain is repeatedly added until all the acid is dis- 
placed. The specimen is now washed in a weak salt solution 
(about 2 per cent.) and examined in this — not in balsam. 

Gram's method stains the diplococcus and its capsule blue- 
black. 

Loffler's methylene-blue stains the diplococcus well, but 
does not stain the capsule. 

Specific stains for the capsule are often unsatisfactory, and 
have little advantage over Loffler's methylene-blue. 

Bacillus Pneumoniae of Friedlander. — This is a larger organ- 
ism than the pneumococcus, and appears in the form of 
plump, short rods surrounded by a capsule. It occurs occa- 
sionally in pneumonia, but is probably not a cause of the 
genuine lobar variety. 

Bacillus of Influenza (PfeifFer). — This germ is found in the 
sputum of this disease, and its recognition is of diagnostic 
importance. Cover-glass preparations are made in the usual 



GENERAL CONSIDERATIONS. 159 

way, and stained with Loffler's methylene-blue for from five 
to ten minutes, washed in water, and mounted in balsam or 
water. 

The organisms appear as extremely small blue rods. The 
end stains more deeply than the middle portion. 

Streptococci and Staphylococci. — These organisms are 
extremely common in sputum, but are not specific in any 
pulmonary disease. They are found especially in tubercu- 
losis, bronchitis (acute and chronic), pneumonia, pulmonary 
gangrene and abscess, etc. 

Actinomycosis. — Actinomycosis has been positively shown 
to be a variety of infections due to different species of strep- 
tothrix, instead of being, as was formerly believed, a single 
disease entity, caused by a single micro-organism (Actino- 
myces bovis). Because of this fact it seems advisable to sub- 
stitute the name streptothricosis for actinomycosis. 

A number of cases of pulmonary streptothricosis have been 
reported in which the physical findings could not be distin- 
guished from those of tuberculosis. The sputum and pus 
from cavities in the lungs contained branched threads which 
were " as acid-fast as tubercle bacilli." Various investigators 
have described several varieties of streptothrix as the cause 
of pulmonary infections. At the present time it is impossible 
to classify them definitely. 

In the pus derived from ulcerating actinomycotic tumors, 
in the sputum of cases of pulmonary actinomycosis, and in 
the faeces of intestinal cases, characteristic yellow granules, 
measuring from 0.5 to 2 mm. in diameter, may be found. 

These granules, when pressed out under a cover-slip and 
examined with the microscope, will be seen to consist of 
numerous threads, which radiate from a centre in a fan-like 
manner and show club-shaped extremities. 

Leptothrix buccalis is a common non-pathogenic mouth 
micro-organism of the fission fungi type. It is frequently 
present in the sputum, and in the unstained specimen has 
been mistaken by beginners for elastic tissue. In pulmonary 
gangrene it is known as Leptothrix pulmonalis. It takes on 
a violet or bluish color when treated with Lugol's solution. 



160 



SPUTUM. 



Oidium albicans, or Saccharomyces albicans, produces a 
stomatitis called thrush, and is seen most often in children and 
tuberculous adults. It belongs to the order of yeast-fungi, 
and consists of branching filaments, from the ends of which 
ovoid torula cells develop (Fig. 53). 

Aspergillus fumigatus, Mucor corymbifer, and Sarcina pulmo- 
nalis may occasionally be found in sputum, but are of little 
importance. 

An important practical point is the fact that a number of 
pathogenic micro-organisms can be found in the sputum or 
mouth in health. Such are Diplococcus pneumoniae, strepto- 

Fig. 53. 




Oiclium albicans, the vegetable parasite of muguet or thrush. (Reduced from 

Ch. Robin.) 

cocci and staphylococci, Bacillus pneumonia} of Friedliinder, 
Bacillus coli communis, and even the bacillus of diphtheria. 

Animal Parasites. — Portions of echinococcus cysts — /. e., 
pieces of membrane and hooklets — are occasionally found in 
the sputum when the parasite has entered the lungs or neigh- 
boring organs. 

Trichomonades, similar to Trichomonas vaginalis, have 
rarely been observed in cases of gangrene of the lungs and 
in the pus removed from lung cavities post mortem. 

Amoeba coli, when found in sputum, make it certain that 
an hepatic abscess has perforated into the lungs. 



GENERAL CONSIDERATIONS. 



161 



Distoma pulmonale, a lung parasite, is the cause of a dis- 
ease resembling phthisis, and occurs frequently in Japan. The 
worm and ova are found in the sputum. 

Bed blood-cells (Fig. 54) in small numbers are found in 
almost every sputum, being derived from inflamed mucous 
membranes. When present in large numbers, they are of im- 
portance, especially in phthisis. They occur in almost all 
pulmonary diseases. The appearance of the red cell depends 
upon the length of time it has been in the lung, and will vary 
from a typical cell to its shadow or a mere fragment. The 

Fig. 54. 







Epithelium, leukocytes, and crystals of sputum. (Eye-piece III., objective 8 A, 
Reichert): a, a', a", alveolar epithelium; b, myelin forms; c, ciliated epithelium; 
d, crystals of calcium carbonate; e, hsematoidin crystals and masses; /,/,/, white 
blood-corpuscles ; g, red blood-corpuscles ; h, squamous epithelium, (v. Jaksch.) 

presence of blood-pigment is not always indicated by a red 
color. It may show a golden-yellow or greenish tinge, having 
undergone certain chemical changes. 

Leukocytes, usually polynuclear, are seen in every sputum. 
In bronchial asthma a large number of eosinophile and even 
basophilic leukocytes are found. The sputum of pulmonary 
abscess, perforating empyema, and putrid bronchitis is made 
up chiefly of degenerating leukocytes. 

Epithelial cells are present in the sputum, but are of little 
importance in determining the location of the pulmonary 
disease. 

11— C D. 



162 SPUTUM. 

The cylindrical epithelial cells are usually so much altered 
that they resemble leukocytes. It has been proved that alve- 
olar epithelial cells occur in almost every known pulmonary 
disease, and also in normal expectoration after a very forcible 
expiration. 

Heart-disease cells are alveolar epithelial cells, containing 
numerous hsematoidin granules. They are found in the sputa 
of bronchitis associated with chronic heart disease (see Fig. 4). 

Crystals. — The following crystals have been found in spu- 
tum : Charcot-Leyden, hsematoidin, chloesterin, margarin, 
tyrosin, calcium oxalate, uric acid, and triple phosphates. 




© ^°e / ® ©/© 



Charcot-Leyden crystals. (Scheube.) 

None of these is of diagnostic importance, although at one 
time Charcot-Leyden crystals were supposed to have an etio- 
logical relation to asthma. They are more often present in 
this disease than in any other pulmonary affection, but they 
have also been found in acute and chronic bronchitis and in 
phthisis (Fig. 55). 

QUESTIONS. 

Describe the correct methods of obtaining and examining sputum. 

Mention the different varieties of sputum. 

Upon what factors do the varying colors of sputum depend ? 

What points are to be considered in the macroscopical examination of 
sputum ? 

What are the chief objects of interest and diagnostic value in the micro- 
scopical examination ? 



MISCELLANEOUS EXAMINATIONS. 163 

Describe elastic tissue and the best method for its examination. 
What is a Curschmann spiral ? 

Name the vegetable parasites found in the sputum. 
Describe Gabbet's method of staining tubercle bacilli. 
What bacilli are most likely to be mistaken for tubercle bacilli ? 
Describe Welsh's method of capsule staining. 

Of what importance is the streptothrix in pulmonary infections ? 
Of what significance are Charcot-Leyden crystals and eosinophile leuko- 
cytes ? 



CHAPTER XL 

MISCELLANEOUS EXAMINATIONS. 

1. CLINICAL BACTERIOLOGICAL EXAMINATIONS. 

Most of this work consumes very little time when carried 
out by microscopical examination of stained cover-slip prepa- 
rations, as described in preceding chapters. 

In case of a mixed infection or difficulty in recognizing 
bacteria by the fresh cover-glass method, it is occasionally 
necessary to resort to more time-consuming examinations, 
such as cultural methods and animal inoculation. 

For this purpose a sterilizing oven, Petri plates, and cult- 
ure-media are needed in addition to apparatus before men- 
tioned. 

Reliable culture-media may be purchased from the lead- 
ing manufacturing pharmacists. The following will serve 
ordinary purposes : 

(1) Bouillon, 2 per cent, glucose-bouillon if desired. 

(2) Agar, 2 per cent, glucose-agar if desired. 

(3) Loffler's blood-serum. 

Bacteria are isolated by means of (1) plate cultures or (2) 
the streak method. 

Plate Cultures. — For this method three sterilized Petri 
plates and three tubes of agar are employed. 

The culture-medium is melted in the tubes by heating over 
a Bunsen flame, and then placed in a hot water-bath. Cool 
melted material below 50° C. and inoculate before solidifica- 



164 MISCELLANEOUS EXAMINATION. 

tion commences. With a sterilized platinum loop the first 
tube is inoculated with two or three loopfuls of the material 
and stirred thoroughly. The platinum loop is sterilized 
again, and the second tube inoculated with two or three loop- 
fuls of material from tube No. 1, and well mixed. 

The loop is sterilized once more, and then tube No. 3 is in- 
oculated with several loopfuls of material from tube No. 2. 
The cotton plugs are again removed and the upper portions 
of the tube heated in the flame and the contents poured into 
Petri dishes. They are now placed in the thermostat or 
set aside at room temperature. In the growth which follows 
the colonies of bacteria are separated. They may now be 
transplanted to different tubes, thus rendering it possible to 
isolate and study them. 

The Streak method is much more simple. The platinum 
loop is charged with the material and drawn several times 
over the surface of the culture-medium. In this way the 
bacteria may be separated and grown in isolated colonies. 
The different bacteria may be recognized by their cultural 
characteristics, or may be transferred to cover-slips and 
studied microscopically. 

Animal inoculation is especially practical clinically for 
the diagnosis of tuberculosis and rabies. Suspected sediments 
are injected into the peritoneal cavities of guinea-pigs or 
rabbits. Solid material is introduced through a small ab- 
dominal incision under aseptic precautions. The symptoms 
are carefully observed, and later a postmortem is performed 
and the necessary bacteriological and histological examina- 
tions made. 

Bacteriological examination of the following bacteria is 
practical, and may be of great value : 

Diphtheria Bacillus. — Spreads may be made directly from 
the throat, stained, and examined microscopically. 

A better method is to inoculate a tube of Loffler's blood- 
serum with the material from the diseased throat. Two 
tubes are required : (1) Loffler's blood-serum ; (2) a tube con- 
taining a swab, made by winding absorbent cotton around a 
wire. Both tubes are plugged with cotton and sterilized. 



CLINICAL BACTERIOLOGICAL EXAMINATIONS. 165 

The sterilized swab is rubbed against the membrane and 
then smeared over the surface of the blood-serum. The swab 
is burned or returned to its tube. The culture-tube is placed 
in the thermostat at 37° C. If diphtheria bacilli are present, 
characteristic colonies should grow in from eighteen to twenty- 
four hours. They are large, elevated, rounded, grayish or 
creamy- white, moist, discrete or confluent, with a centre 
denser than the periphery. 

Spreads are made from these colonies and stained with 
Loffler's methylene-blue or by Gram's method. The bacillus 
is nonmotile, 2.5 to 3 /jl in length, 0.5 to 0.8 fi in thickness. 
It is a straight or slightly bent rod, with rounded ends. 
Irregular forms are common, such as rods with one or both 
ends swollen. They stain unevenly — some areas deeply, 
others slightly — giving a beaded or segmented appearance. 
The most characteristic thing about this bacillus, and one 
which greatly facilitates its recognition, is the presence of 
small granules near the poles of the bacillus, which stain blue 
with Neisser's method, while the body of the organism is 
colored brown. Streptococci and staphylococci frequently pro- 
duce exudates in the throat which resemble the diphtheritic 
membrane. 

Tubercle Bacillus. — Because of their small numbers, it is 
often impossible to demonstrate tubercle bacilli in urine, exu- 
dates, transudates, etc., by staining methods. Animal inocu- 
lation should then be resorted to. The fluid is centrifugated 
and the sediment injected. 

In examining urine, faeces, and genito-urinary discharges 
for the tubercle bacilli, the spread should always be decolor- 
ized in alcohol, in addition to nitric acid, in order to exclude 
the smegma bacilli. Pappenheim's stain may be used for this 
purpose. 

Diplococcus Intracellulars Meningitidis. — This resembles 
the gonococcus in its morphology and staining properties. It 
is associated with infectious cerebrospinal meningitis, and is 
obtained from the cerebrospinal fluid and meningeal exudates. 

Micrococcus lanceolatus of pneumonia is recognized by 
staining methods. (See Sputum.) 



166 MISCELLANEOUS EXAMINATION. 

Cerebrospinal Fluid.— Examination of this fluid may be 
of great diagnostic aid in diseases of the cerebrospinal tissues, 
especially in meningitis. 

There may be inflammatory, suppurative, hemorrhagic, and 
dropsical processes ; one looks for alterations in the amount, 
appearance, specific gravity, quantity of albumin, and the 
presence of pus, blood, and bacteria. The presence of a 
turbid fluid is important. The chief examinations are macro- 
scopical, microscopical, and bacteriological. 

The fluid should be centrifugated, spreads made from the 
sediment, stained, and examined for the various bacteria with 
the oil immersion. 

The tubercle bacillus, Diplococcus intracellularis meningi- 
tidis, Micrococcus lanceolatus, staphylococcus, streptococcus, 
and typhoid bacillus are the chief causes of meningitis. 

The spreads should be stained by appropriate methods. 
If the microscopical examination is unsatisfactory, cultural 
methods or animal inoculation should be resorted to. 

Lumbar Puncture. — Cerebrospinal Fluid as Obtained by 
Lumbar Puncture. — This simple operation should be performed 
in all obscure conditions suggesting cerebrospinal involve- 
ment. The patient should lie on the side, with the back bent 
forward as far as possible, in order to separate the vertebrae 
and make the lumbar region prominent. 

The sitting posture may also be assumed with the back 
bent forward. A local anaesthetic is usually all that is neces- 
sary. Very often the patient is comatose and requires none. 
A long, strong, aspirating-needle is introduced midway 
between the second and third or third and fourth lumbar 
vertebrae, about an inch to the side, and directed a trifle 
inward. It should be inserted from 2 to 3 cm. in a child and 
from 7 to 8 cm. in the adult. As soon as the subarachnoid 
space is entered, the fluid makes its appearance, usually drop 
by drop ; but when large in amount and under great pressure, 
in a stream. 

Normal cerebrospinal fluid is a clear, limpid, noncoagulating 
liquid, with a specific gravity of 1005 to 1007. Microscopi- 
cally a few endothelial cells, leukocytes, and fibrin-filaments 



CLINICAL BACTERIOLOGICAL EXAMINATIONS. 167 

may be seen. A few cubic centimetres of fluid can nearly 
always be obtained. It is increased in hydrocephalus and 
meningitis; in some cases 100 c.c. have been withdrawn. 

In fibrinous and purulent conditions it is decreased, or can 
not be obtained. The same is true in adhesions or when 
tumors press upon the canal. 

Articular Fluid. — Examination of synovial fluid — obtained 
by aspiration or incision — may throw considerable light upon 
the nature of the disease. The same methods of examination 
should be followed as in the above. 

Transudates and exudates of the various cavities of the 
body, pleura, pericardium, and peritoneum, should be exam- 
ined in the same way. Frequently by microscopical and cult- 
ural means, or animal inoculation, the etiological factor can 
be discovered. 

The examination of the sediment of the various exudates 
by staining with hematoxylin may be of value in the diag- 
nosis of malignant growths of the serous membranes. Dock 
has found that in cancerous effusions there are more cells 
showing mitoses than in simple or tuberculous inflammations. 

Transudates are found in noninflammatory conditions, and 
are usually clear and light yellow in color, while exudates are 
found in inflammatory conditions and are darker in color and 
turbid. 

The specific gravity of transudates is usually below 1018 ; 
while in exudates it is usually above this figure, and may 
reach 1030. 

Exudates contain much more albumin. 

Microscopically the transudates are free from microorgan- 
isms, and show only a few isolated leukocytes and endothelial 
cells. 

Exudates contain many more formed elements, and may be 
serous, serofibrinous, seropurulent, purulent, putrid, hemor- 
rhagic, chylous or chyloid. They may be free from micro- 
organisms, but more often they are not. 

In empyemas, various streptococci and staphylococci, the 
pneumococcus, and FrankePs diplococcus may be found. If 
entirely free from microorganisms, tuberculosis should be 



168 MISCELLANEOUS EXAMINATION. 

suspected. Pus made up of a large percentage of mono- 
nuclear leukocytes instead of perinuclear strongly suggests 
a tuberculous origin. 

Discharges from the various mucous membranes of the body, 
such as the urethral, vaginal, nasal, conjunctival, etc., should 
be examined microscopically by means of spreads and appro- 
priate stains. 

Average Human Milk. — Analysis taken from Rotch's Pedi- 
atrics : 

Reaction, amphoteric or slightly alkaline. 
Specific gravity, 1028 to 1034. 

Water 87 to 88 per cent. 

Total solids 12 to 13 " 

Fats 3 to 4 " 

Milk-sugar 6 to 7 " 

Proteids 1 to 2 " 

Total mineral matter 0.1 to 0.2 " 



Average Cows' Milk. — 

Reaction, slightly acid. 
Specific gravity, 1029 to 1033. 

Water 86 to 87 per cent. 

Total solids 13 to 14 

Fats 4 

Sugar 4.5 

Proteids 4 

Total mineral matter 0.1 



Laboratory examination of milk may be of value from 
the standpoint of infant feeding. 

The specific gravity and the determination of the per cent, 
of fat are the two chief practical tests, since the other solid 
ingredients vary proportionately with the fat. From these a 
fairly accurate idea of the nutritive strength of the milk can 
be gained. The total solids can be approximately calculated 
(for cows' milk) by adding 1.2 times the per cent, of fat to 
one-fourth of the specific gravity at 15° C. 

Fat Estimation. — This is most easily made by means of 
the lactoscope of Feser. Draw milk into the pipette up to 
the mark M; empty into cylinder C. Einse pipette with 



CLINICAL BACTERIOLOGICAL EXAMINATIONS. 169 

water and add washings to the milk. Shake and add water 
until the black lines upon the milk-colored glass plug A can 
just be discerned. The height to which the mixture reaches 
is noted on the scales. The figure on the right indicates the 
percentage amount of fat, while that on the left indicates 
the number of cubic centimetres of water w r hich have been 
added. 

The simplest method of determination of fat is by the cream 
gauge (Holt) (Fig. 50). Although its results are only approx- 
imate, they are in most cases sufficiently accurate for clinical 
purposes. 

The tube is filled to the zero mark with freshly drawn 
milk, which stands at a room temperature for twenty-four 
hours, when the percentage of cream is read off. The ratio 
of this to the fat is approximately 5:3; thus 5 per cent, 
cream indicates 3 per cent, fat, etc. For a more accurate 
determination the best ready method is probably the modifi- 
cation by Lewi of the Leffmann and Beam test for cows' milk. 
This is a centrifugal test requiring special tubes (made by 
Richard & Co., New York) used in the ordinary centrifuge 
for urine. Only 6 c.c. of milk are necessary ; and if care- 
fully made the results are almost as accurate as by a chemical 
analysis. 

The Babcooh fat-tester is frequently employed. Equal 
volumes of milk and commercial sulphuric acid are mixed in 
a test- bottle which has a long, graduated neck. This is cen- 
trifugated at once — while still hot. After whirling, the bottle 
is filled to the neck with hot water, returned to the machine, 
and whirled again for one or two minutes, after which it is 
filled with hot water to about the 7 per cent. mark. It is 
again whirled for a short time. The fat separates and its 
percentage is noted on the scale. 

Specific Gravity. — This is best determined with the lacto- 
densimeter of Quevenne. The instrument is graduated for 
a temperature of 60° F., so it is necessary to correct the spe- 
cific gravity for different temperatures. The error, however, 
is very small, and if taken at room temperature need not be 
considered. 



170 URINALYSIS. 

QUESTIONS. 

Mention several important culture-media. 
Describe the plate culture method of isolating bacteria. 
Describe the streak method. 

What is meant by animal inoculation, and when is it indicated ? 
Describe in detail the correct method of making a bacteriological exami- 
nation in a case of diphtheria. 

Of what importance is examination of cerebrospinal fluid ? 
Describe the method of making lumbar puncture. 
What is the difference between a transudate and an exudate ? 
What are the two chief practical tests in the examination of milk ? 
Mention several methods for determining fat per cent. 



CHAPTER XII. 

UKINALYSIS. 

APPARATUS AND REAGENTS USED IN URINALYSIS. 

1. Test-tube, 4 and 6 inches. 

2. Test-tube stand and brush. 

3. Urinometer (preferably Squibb's). 

4. Doremus ureometer. 

5. Esbach's albuminirneter. 

6. Burette graduated in 0.2 or 0.1 c.c. 

7. Graduated cylinders, 100 c.c. and 500 c.c. or 1000 c.c. 

8. Flasks of several sizes. 

9. Conical glasses. 

10. Nest of beakers. 

11. Set of porcelain evaporating dishes. 

12. Glass funnels, 2-inch and 5-inch. 

13. Nipple pipettes, 1 c.c. 

14. Glass tubing of different sizes. 

15. Glass rods of different sizes. 

16. Bunsen burner or alcohol lamp. 

17. Centrifuge, centrifuge tubes. 

18. Litmus-paper, blue and red. 

19. Filter-paper, to fit funnels. 



APPARATUS AND REAGENTS USED IN URINALYSIS. 171 

20. Small file. 

21. Slides and cover-slips. 

22. Stains — carbol-fuchsin, methylene-blue, Gram's stain. 

23. Microscope. 

Several test-tubes should be file-marked in order that the 
same quantities of reagents and urine may always be used in 
making such tests as the diazo, indican, etc. 

Esbach's Reagent. — 10 grammes of picric and 20 grammes 
of citric acid, dissolved in 1000 c.c. of distilled water. 

Fehling's Solutions. — Two solutions, kept in separate rubber- 
stoppered bottles. 

Solution I. : 34.64 grammes of pure crystallized copper 
sulphate, dissolved in distilled water and diluted to 500 c.c. 

Solution II. : 173 grammes of tartrate of potassium and 
and sodium, and 60 grammes of sodium hydrate dissolved in 
distilled water, and diluted to 500 c.c. 

Purdy's Solution for Sugar Determination. — 

Pure cupric sulphate, 4.752 grammes ; 

Potassium hydroxide, 23.50 grammes ; 

Strong ammonia (U. S. P., specific gravity 0.90), 350 c.c. ; 

Glycerin, 38 c.c. ; 

Distilled water, to 1000 c.c. 

Prepare by dissolving the cupric sulphate and glycerin in 
200 c.c. of distilled water with the aid of gentle heat. In 
another 200 c.c. of distilled water dissolve the potassium 
hydroxide. Mix the two solutions, and when cooled add the 
ammonia. Finally with distilled water bring the volume of 
the whole up to exactly 1000 c.c. 

Diazo Solutions. — 

( Sulphanilic acid, 1 gramme ; 

Solution I. < Hydrochloric acid (concentrated), 50 c.c. ; 
( Distilled water, ad., 1000 c.c. 

q i , . tt f Sodium nitrite, 0.5 gramme ; 
* \ Distilled water, ad., 100 c.c. 

The nitrite solution readily oxidizes to nitrate ; it is there- 
fore necessary to keep it in a well-stoppered bottle. It should 
be fairly fresh. 



172 URINALYSIS. 

Hypobromite solution, for Doremus ureometer. 

Solution 1. / Rustic soda 100 grammes ; 

( Distilled water, 250 c.c. 

Solution 2. Bromine. 

Sudan III. Test Solution. — Saturate a certain amount of 
alcohol with Sudan III. After standing several days, 1 part 
of this solution is mixed with 1 part of alcohol and 1 part of 
water. It is turbid at first, but clears on standing. 

Lugol's Solution. — 

Iodine, 1 gramme; 

Potassii iod., 2 grammes ; 

Water, 300 c.c. 

Silver Nitrate Solution. — Dissolve 5 grammes of silver 
nitrate in distilled water and dilute to 100 c.c. Keep in 
dark-colored bottles. 

Ferrocyanide of Potassium Solution. — Dissolve 10 grammes 
of potassium ferrocyanide in water enough to make 100 c.c. 

Ferric Chloride Solution. — Dissolve 10 grammes of ferric 
chloride in enough water to make 100 c.c. 

Potassium or Sodium Hydrate Solution. — Dissolve 10 
grammes in 100 c.c. of water. 

Barium Chloride Solution. — Dissolve 10 grammes of barium 
chloride in enough water to make 100 c.c. 

Nitric acid (HNO s ), sp. gr. 1.42. 

Hydrochloric acid (HC1), sp. gr. 1.20. 

Sulphuric acid (H 2 S0 4 ), sp. gr. 1.84. 

Ammonium hydrate (NH 4 OH), sp. gr. 0.96. 

Glacial acetic acid (HC 2 H 3 2 ). 

Ether. 

Chloroform. 

Distilled water. 

Sodium nitroprusside powder. 

Phenylhydrazin hydrochloride. 

Sodium acetate. 

Sodium chloride. 



APPARATUS AND REAGENTS USED IN URINALYSIS 173 

Value of Urinalysis. — A properly made analysis of urine 
may furnish much valuable information concerning body 
metabolism, the diagnosis and prognosis of both renal and 
other diseases. On the other hand, an enormous amount of 
valuable time and labor may be wasted by ill-judged resort 
to quantitative analyses, such as estimations of urea, uric 
acid, phosphates, sulphates, etc. These estimations are on 
occasions of value, but as ordinarily made by anyone except 
an expert are worse than useless. For instance, urea is often 
estimated for a single day or in a separate portion of urine ; 
the nitrogen intake through the food is not regarded, and the 
nitrogen passed in the faeces is not taken into consideration in 
the calculation. No diagnostic, prognostic, or therapeutical 
deductions can be drawn from such examinations ; in fact, 
they may be very misleading. To be of value, quantitative 
estimations must be made for a number of days in succession, 
under known conditions of diet, rest, etc. In most cases in- 
formation of much greater value can be obtained by the more 
simple and easily applied qualitative tests and the micro- 
scopical examination of the sediment. 

Characteristics of Normal Urine. — Recently passed nor- 
mal urine is clear, with no visible cloud or sediment ; turbidity 
in freshly passed urine in the majority of cases indicates an 
abnormal condition. However, at certain times during the 
day, especially two to three hours after a heavy meal, the 
freshly passed urine in health may be distinctly turbid from 
the presence of amorphous phosphates. After standing for 
some time a normal urine develops a light cloud which settles 
to the bottom. This cloud consists of mucus, containing a 
few round granular cells, somewhat larger than normal leuko- 
cytes, so-called mucous corpuscles, and a few pavement epi- 
thelial cells derived from the genito-urinary organs. 

In normal urine which is allowed to stand for some time at 
ordinary temperature, and more quickly at a somewhat ele- 
vated temperature, certain important changes take place as 
the result of the development of ammoniacal fermentation. 
The reaction gradually changes from acid to alkaline ; a bulky 
sediment forms, made up of triple phosphates, earthy phos- 



174 URINALYSIS. 

phates, and ammonium urate, in addition to enormous num- 
bers of bacteria. The supernatant liquid is permanently 
cloudy even after filtration, owing to the presence of numer- 
ous bacteria. Freshly voided urine exhibiting such a sedi- 
ment indicates the presence of germs in the genito-urinary 
tract. If urine be kept in a cool place, this decomposition 
may be delayed for days, and instead a deposit of amorphous 
urates or uric acid may appear. 

A recognition of the fact that such marked changes in urine 
can take place on standing is of great practical importance. 
It emphasizes the necessity of examining fresh samples of 
urine, especially in warm weather. The tests for albumin 
and sugar, and the microscopical examination of the sedi- 
ment in particular, are very unsatisfactory in decomposing 
urines; not only this, but they may also lead to a wrong 
diagnosis. 

The amount of urine varies much in health, depending on 
many factors, such as the quantity of liquid taken, variety of 
food ingested, amount of water lost through the skin, bowels, 
and lungs ; age, sex, and season also cause variation in the 
amount. The limit may be placed at 600 to 1800 c.c.; and 
yet even these limits may be exceeded in some instances. 
The average for the adult in the United States, according to 
Simon, is 1000 to 1200 c.c. for twenty-four hours for men 
and a trifle less for women. Children pass relatively more 
than adults. The amount of solid matter in the urine is also 
higher for men than for women. 

In disease the amount may vary from none at all, as in 
complete suppression (anuria), or a few ounces as in acute 
Bright's disease (oliguria), to several litres (polyuria), as in 
diabetes mellitus or insipidus and chronic interstitial nephritis. 

The quantity is measured with graduated cylinders. 

The specific gravity of urine is as variable as the quantity, 
ranging ordinarily from 1015 to 1025 ; these limits, however, 
can be extended considerably in health. It depends upon the 
quantity of solids in solution. In disease the specific gravity 
may be high with a large volume, as in diabetes mellitus, or 
low with a small volume, as in many chronic w r asting diseases 



APPARATUS AND REAGENTS USED IN URINALYSIS. 175 

and in the later stages of acute disease, indicating defective 
elimination of solids. 

In estimating the specific gravity, the Squibb urinometer is 
used for routine work. For very accurate estimations the 
Lohnstein urinometer is best, especially in making the fer- 
mentation test for sugar. The following precautions should 
be observed : the urinometer should not adhere to the side of 
the cylinder ; all foam should be removed from the surface of 
the urine with filter-paper ; the reading should be taken at the 
lower meniscus. If great accuracy is essential, the tempera- 
ture of the urine must be taken into consideration, since the 
specific gravity increases or decreases 1 degree for every 3 
degrees Centigrade above or below 15° C, the temperature at 
which the instrument is standardized. For most clinical work 
the temperature is disregarded provided the urine be at the 
room temperature. 

Reaction of Urine. — Normally the reaction of the twenty- 
four hours' urine, and also of separate portions, is acid ; but in 
many healthy people, at different periods of the day, it is 
faintly acid, neutral, or even faintly alkaline, especially after 
hearty meals. The urine of those living on strictly vegetable 
diet will usually be very faintly acid or alkaline. The acidity 
is due to diacid phosphate, chiefly of sodium, while alkalinity 
is due to the monoacid or primary phosphates and to carbon- 
ates of sodium and potassium. 

Litmus-paper is used to test the reaction ; acid urine turns 
blue litmus red, alkaline urine turns red litmus blue. Neu- 
tral urine does not change the color of either. 

Color. — This varies from a very light yellow or even watery, 
to a very dark brownish yellow. The depth of color is pro- 
portional to the amount of water present, and thus to the dilu- 
tion of urinary pigments. 

Pathologically the color of urine varies a great deal. It 
may be the color of water in the polyuria of nervous condi- 
tions and chronic interstitial nephritis. In febrile conditions 
it is usually very highly colored. The red tints of urine are 
usually due "to the presence of blood ; the dark-brown tints 
may be due to methsemoglobin. The urine may be almost 



176 URINALYSIS. 

black in the presence of melanotic cancer, especially after 
standing for some time. Bile gives a brownish or greenish- 
brown color. Blue urine may be present in cholera and 
typhus, owing to the presence of indigo. Certain drugs alter 
the color of urine. Turbidity in urine may be due to pus, 
urates, phosphates, bacteria, and epithelium. 

Acid urines, as a rule, are darker in color than alkaline. 

The odor of normal urine is characteristic ; after eating cer- 
tain substances or administration of certain drugs more or less 
peculiar odors are imparted. If ammoniacal fermentation has 
taken place, the urine smells of ammonia; if the urine is 
decomposed, a strong, putrid, ammoniacal odor is noticed. 
Acetone is easily recognized if present in any quantity by a 
fruity odor. Rarely, however, is the odor of clinical value, 
though it may give a clue. 

Constituents of Normal Urine. — Normal urine is a 
watery solution of the waste products of metabolism and the 
decomposition products of excess of ingested food. It is evi- 
dent that the composition will vary from hour to hour during 
the day, being a very dilute solution after eating or drinking, 
and very concentrated in the early morning hours. The total 
amount of urine passed by an individual in one day will, 
however, be very nearly the same in composition as that of 
another day, other things being equal. The constituents of 
urine may be divided into two groups, organic and inorganic, 
or mineral. Of these, the most important are : 

Organic. — Urea, uric acid, and alloxuric or xanthin bases ; 
creatinin ; hippuric acid ; indoxyl, phenol, and cresol as con- 
jugate sulphates; other sulphur compounds (neutral, orunox- 
idized sulphur) ; pigments and chromogens. 

Inorganic. — Chlorides, sulphates, phosphates of sodium, 
potassium, calcium, magnesium, and ammonium. Oxalates 
and carbonates may be present also. 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 177 

CONSIDERATION OF THE IMPORTANT NORMAL CON- 
STITUENTS OF THE URINE, VARIATIONS IN THE 
QUANTITY OF WHICH MAY INDICATE DISEASE. 

Water. — Upon this constituent depend the concentration 
and dilution, and consequently the quantity of urine excreted. 
It varies much in amount, depending upon many factors such 
as are mentioned under Amount 

Solids. — The total daily amount of solids excreted in the 
urine is more constant than that of the water. If estimated 
for a number days in succession under known conditions, it 
may be of clinical value. One estimation is a waste of time. 

Composition of Normal Urine (Bliss) : 

Organic matter, about 35 grammes. 

Urea, about 30 grammes. 

The remaining organic matter consists principally of uric 
acid, hippuric acid, creatinin, extractives, and coloring-matter. 

Mineral matter, about 25 grammes. Half to two-thirds of 
this consists of sodium chloride; the remainder is made up 
of sulphates, chlorides, and phosphates of the alkalies and 
alkaline earths. 

Urea, CO^ t\xtt 2? is the most important nitrogenous con- 
stituent of the urine. It is of clinical significance, since it 
to a large extent represents the nitrogenous katabolism of the 
body. Under normal conditions it represents about 85 per 
cent, of the total nitrogen eliminated by the kidneys. The 
normal daily amount of urea excreted in the urine varies 
from 25 to 35 grammes. The liver is held to be the seat 
of the formation of urea. 

Simon says : " It might be supposed that an accurate 
idea of tissue destruction could be formed from a quantita- 
tive estimation of the urea. This is not the case, since, in 
pathological conditions especially, the quantitative relations 
existing between the excretion of urea and the remaining 
nitrogenous constituents is subject to wide variations. The 
urea may disappear entirely from the urine, the nitrogen 
being eliminated in the form of other compounds. So it is 
12— c. D. 



178 URINALYSIS. 

necessary to determine the total nitrogen excreted by the kid- 
neys when one wishes to gain an accurate insight into the 
nitrogenous metabolism. 

The elimination of urea, and of nitrogen in general, is sub- 
ject to great variations, depending on the amount of nitrogen 
ingested, and that resulting from tissue destruction, which in 
turn is largely influenced by the body weight. The elimina- 
tion of nitrogen should always be compared with the amount 
of food ingested. A variable amount (in disease it may be 
considerable) of nitrogen is eliminated in the faeces; conse- 
quently this factor must be reckoned with if accurate conclu- 
sions are to be drawn. 

The tediousness and the difficulty of such estimations 
render them entirely impractical. Approximate results can be 
obtained by parallel estimation of chlorides. In health the 
amount of the chlorides is equal to about one-half that of the 
urea. Whenever the amount of urea is greatly in excess of 
the normal amount of chlorides, an increased tissue destruc- 
tion may be inferred, and vice versa. 

Urea is increased in amount in fevers, diabetes, excessive 
bodily exercise; and with a meat diet. An important clinical 
point is the fact that its total excretion is diminished in 
uraemia, kidney diseases with impaired excretory power, in 
liver diseases such as cirrhosis, in which the urea-form- 
ing function of the organ is impaired. Little is definitely 
known about the relation of urea, uric acid, etc., to gout and 
lithsemia. In certain diseases of the kidney the amount of 
urea formed may be decreased, but the kidneys are unable to 
excrete all ; and in certain liver diseases, while the amount 
of urea formed is diminished, the nitrogenous substances 
which go to urea formation are eliminated and the total nitro- 
gen excreted remains the same. 

Characteristics of Urea. — Owing to its ready solubility, it 
appears in the urine in solution. In concentrated solution it 
is precipitated in the form of crystals of nitrate of urea on 
the addition of nitric acid. This is shown in the applica- 
tion of Heller's test, urea nitrate crystals forming just above 
the junction of the two liquids. 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 179 

Urea is converted into ammonium carbonate by certain 
bacteria (CON 2 H 4 + 2H 2 = (NH 4 ) 2 C0 3 ). This is the com- 
monly observed ammoniacal decomposition which is seen 
whenever urine stands for a length of time at ordinary tem- 
perature, and in pathological conditions inside the bladder, as 
in cystitis, etc. 

Xanthin bases enter into the formation of the nucleins, the 
essential chemical constituents of the nuclei of body-cells. 
Those in the urine are derived from food and nuclear katab- 
olism. They have practically the same origin, significance 
and fluctuations as uric acid. The quantity is ordinarily 
about one-tenth that of uric acid. Clinically they have the 
same significance. 

Uric acid is an oxidation product of the xanthin bases, 
and the chief form in which they are excreted. It represents 
the katabolic breaking down of the cell-nuclei. 

The amount of uric acid excreted daily in the urine varies 
from 0.4 to 0.8 gramme, having a proportion to the amount 
of urea excreted of 1 : 40 to 1 : 60. Physiologically it is 
increased by the ingestion of food rich in cells, such as liver, 
kidney, etc. ; pathologically, by increased breaking down of 
tissues. 

Uric acid is increased in conditions attended with leukocy- 
tosis, such as leukaemia (may be 5 grammes in twenty-four 
hours), pneumonia, etc. ; and in febrile conditions, acute rheu- 
matism, and in so-called uric acid diathesis. It is dimin- 
ished in leukopenic and anaemic conditions, and especially in 
kidney diseases associated with uraemia. 

Characteristics. — Uric acid has a strong tendency to crys- 
tallize upon contact with any solid substance. This fact ex- 
plains the large percentage of uric acid calculi. The deposit 
of uric acid is pathological if it occurs in urine passed within 
four to six hours. Normal urine deposits uric acid after 
standing ten hours or more. If uric acid is deposited soon 
after being voided, it suggests the possibility of its being 
deposited in the urinary tract, with the formation of gravel 
and uric acid calculi. 

The chief form in which uric acid occurs in the urine is 



180 URINALYSIS. 

as the urates of sodium, potassium, calcium, and magnesium. 
High acidity forces the uric acid from these combinations. 
They are more soluble than uric acid, and more so in warm 
than in cold liquid. The mixed urate deposit is a reddish, 
granular-looking sediment, the so-called "brick-dust deposit." 
It may vary from a pink to a brick-red. This deposit dis- 
solves on heating the urine. It gives the murexid reaction, 
similar to uric acid. It dissolves in solutions of the caustic 
alkalies, and is decomposed by mineral acids with precipita- 
tion of uric acid crystals. 

Hippuric acid, benzoic acid, and creatinin are found in 
very small amounts in normal urine. Time spent in their 
examination is wasted from the clinical standpoint. 

Ammonium compounds, similar to the corresponding 
sodium and potassium salts, are normally excreted in small 
amounts. 

Total nitrogen in the urine is represented by the above sub- 
stances. It gives a more exact idea of nitrogenous metabo- 
lism than urea alone. 

Sulphates. — The sulphur of the urine is excreted chiefly in 
the form of mineral sulphates and the conjugate or ethereal 
sulphates. They resemble urea in being produced chiefly by 
the decomposition of albuminous material, either taken in with 
the food or that broken down in katabolic processes. The 
quantity varies from 1 .5 to 3 grammes daily, calculated as 
S0 3 , fluctuating parallel to urea. 

Mineral sulphates make up the bulk (nine-tenths) of the 
urinary sulphates. Sodium sulphate is most abundant, with 
a small proportion of potassium, ammonium, and perhaps cal- 
cium and magnesium sulphates. These salts all appear in 
solution. Calcium sulphate very rarely appears in the sedi- 
ments. 

Conjugate Sulphates. — Indol, phenol, and similar sub- 
stances generated in the course of albuminous decomposition 
become oxidized and combine with potassium or sodium 
sulphate to form the conjugate or ethereal sulphates. They 
make up about one-tenth of the excreted sulphates. They 
are formed in the intestine, absorbed, and then excreted by 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 181 

the kidneys, chiefly as indoxyl potassium sulphate — i. e. (in- 
dican), phenol potassium sulphate, potassium sulphates of 
cresol and traces of catechol, and skatoxyl. 

Indican is the most conspicuous, and may be taken as rep- 
resentative of this class. Increase of indican indicates an 
increase of the total ethereal sulphates, and thus an increase 
in bacterial putrefaction in the intestine. 

Unoxidized Sulphur Compounds. — Only small amounts of 
sulphur other than sulphates occur in the urine normally. 
Pathologically cystin and other substances are found ; hydro- 
gen sulphide may be absorbed from the intestine in putrefac- 
tive processes or from foul abscesses, and be excreted by the 
kidneys. It is usually associated with indican. 

Sulphates are increased by meat diet, excessive exercise, 
acute fevers, especially acute rheumatism and meningitis, 
leukaemia, etc. 

Conjugate sulphates are small or large, depending on the 
extent of intestinal decomposition. They are increased in the 
various gastric and intestinal diseases (in practice this fact is 
chiefly noted by the test for indican). 

Phosphates. — The quantity excreted varies between 2.5 and 
3 grammes, depending largely on the amount ingested, in- 
creasing with animal, decreasing with vegetable diet. A cer- 
tain amount is derived from the katabolism of body-tissue, 
muscle-cell, bone, nerve-cell, blood-corpuscles. Some tissues 
(nerve) contain more phosphorus than others. The normal 
proportion between the excretion of phosphoric acid and 
nitrogen is 1 : 7. 

In urine phosphates occur as sodium, potassium, calcium, 
and magnesium salts of the tribasic acid, H 3 P0 4 . Most im- 
portant of these is diacid sodium phosphate, NaH 2 P0 4 , to 
which the acidity of the urine is principally due. The phos- 
phates vary with the reaction of the urine. In acid urine 
there are diacid sodium phosphate and diacid calcium phos- 
phate ; in amphoteric urine, besides these are found disodium 
phosphate, monocalcium phosphate, and monomagnesium 
phosphate ; in alkaline urines, trisodic phosphate, neutral cal- 
cium phosphate, and neutral magnesium phosphate may be 



182 URINALYSIS. 

present. The alkaline phosphates exceed the earthy phos- 
phates by about one-third. Sodium is combined with more 
of the phosphoric acid than potassium. Alkaline phosphates 
of sodium and a small amount of potassium are freely soluble 
in fluids of any reaction, and only appear in the urine in 
solution. The normal excretion amounts to 1.5 to 3 grammes 
daily, calculated as P 2 5 . 

Earthy Phosphates are those of calcium and magnesium. 
They are practically insoluble in pure water, very readily 
soluble in acid, insoluble in alkaline fluids. In alkaline urine 
they occur as a white precipitate. Earthy phosphates may 
be precipitated by heating urine, but the urine clears up on 
adding a drop or so of acid. 

Phosphates are decreased in most acute fevers, the degree 
corresponding to the severity of the disease. This is due to 
failure of excretion. They are also decreased in acute and 
chronic nephritis, anaemia, hysteria, chronic lead-poisoning, 
acute yellow atrophy of the liver, cirrhosis of the liver, etc. 
An increase occurs in the so-called " phosphatic diabetes," 
some nervous diseases, some bone diseases, starvation, and 
convalescence. 

Triple phosphate, ammoniomagnesium phosphate, indicates 
ammoniacal fermentation, occurring either within the bladder 
(fresh urine) or outside the bladder. 

Chlorides. — These are excreted almost entirely as sodium 
chloride, with a small amount of potassium, ammonium, cal- 
cium, and magnesium chlorides. From 10 to 16 grammes 
are excreted in twenty-four hours. They are derived from 
the food (surplus over body need), not from body metabo- 
lism, and thus vary in health with the habits of the indi- 
vidual. Their estimation is at times of clinical importance. 
They are diminished in most acute fevers (the degree depend- 
ing on the severity of the disease), excessive secretion of gas- 
tric juice, exudations and transudations, these withdrawing 
the chlorides that would otherwise appear in the urine. They 
are increased during the absorption of exudates and transu- 
dates, in convalescence, and in polyuria. 

Oxalic acid is present in normal urine in very small 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 183 

amounts. It is derived chiefly from vegetable foods. It 
may be derived in part from uric acid through a process of 
oxidation, or from carbohydrates from incomplete oxidation. 
The quantity is small, varying from a faint trace to 20 milli- 
grammes in twenty-four hours. The recognition of calcium 
oxalate crystals in the sediment is ordinarily taken as an index 
of the excretion, but is misleading, since with a quantitative 
diminution in the excretion there may be numerous crystals 
of calcium oxalate, and vice versa. 

Oxalic acid is increased in gastro-intestinal disturbances, 
diabetes, and in some cases of albuminuria, and in the so-called 
oxalic acid diathesis. This fact is determined in practice 
chiefly by recognition of calcium oxalate crystals in the sedi- 
ment, but the method is untrustworthy. The frequent pres- 
ence of calcium oxalate crystals in the urine of an individual 
should lead to suspicion that it may be deposited within the 
bladder and thus cause the formation of calculus. 

Pathological Substances. — As a result of disease of the 
genito-urinary system, or of local or general disease in other 
parts of the body, or of altered metabolism, any of the above- 
mentioned constituents of normal urine may be either 
increased or diminished. More important than this, however, 
is the occurrence of additional substances. These are as 
follows : 

1. Proteids: serum-albumin, serum-globulin, and albu- 
mose. Of very rare occurrence are nucleo-albumin, fibrin, 
and mucin. 

2. Carbohydrates: glucose; less frequently lsevulose, lac- 
tose, sucrose, maltose. Very rarely are pentoses, glycogen, 
dextrin, animal gum, and inosite found. Normal urine con- 
tains a trace of glucose, barely enough to respond to the most 
delicate tests, and not enough to interfere with any clinical tests. 

3. Acetone, aceto-acetic or diacetic acid, /?-oxybutyric acid. 

4. Diazo substances. 

5. Ammonia. 

6. Bile, bilirubin, bile salts. 

7. Blood and its constituents : albumin, blood-corpuscles 
(red and white), haemoglobin and its derivatives. 



184 * URINALYSIS. 

8. Pus-cells — when few in number called leukocytes. 

9. Casts ; cylindroids. 

10. Spermatozoa. 

11. Epithelium. 

12. Tissue debris, floating particles, etc. 

13. Clap-threads, mucous threads. 

14. Crystals of various normal and abnormal substances, 
amorphous debris, and calculi. 

15. Parasites, vegetable and animal. 

Less important constituents are fat, volatile and nonvolatile 
fatty acids, lactic acid, alcohol ; glycuronates, glycerin-phos- 
phoric acid, alkapton ; cystin, xanthin, cholesterin, leucin, 
tyrosin, ferments, and toxins. 

Albumins. — Of the several albumins mentioned on another 
page, serum-albumin is of the greatest clinical importance. 
When speaking of urinary albumin this variety is always in- 
dicated. 

The presence of albumin in the urine must always be con- 
sidered abnormal, though the clinician must keep in mind that 
it may be transient and unimportant, as in the so-called 
" physiological albuminuria." Even in this variety there is 
probably disturbance in the nutrition of the epithelium of the 
capillaries of the tufts, or of the cells surrounding the glome- 
rulus. 

Albumin is present in the urine in the following conditions, 
varying greatly in amount : 

(a) Functional albuminuria ; (b) febrile albuminuria ; (c) 
hsemic changes — i. e. } purpura, scurvy, chronic poisoning by 
lead or mercury, syphilis, leukaemia, severe anaemia, bile and 
sugar in the blood ; (d) certain nervous diseases (neurotic 
albuminuria), after epileptic attacks, apoplexy, tetanus, blow 
on the head, etc. ; (e) congestion of the kidney, active or 
passive ; (/) organic diseases of the kidney — acute and 
chronic, Bright's disease, amyloid and fatty degeneration, 
suppurative nephritis, and tumors ; (g) all affections of the 
pelvis, ureter, bladder, and urethra associated with the forma- 
tion of pus ; (/*) haemorrhage along the urinary tract. 

Serum-globulin is always found together with serum-albu- 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 185 

rain; in amyloid degeneration the proportion is unusually 
high. It responds to the same tests and has the same signifi- 
cance. 

Albumose (Peptone). — Traces of albumose are found in 
many acute diseases, and in chronic suppuration. Albumose 
often accompanies serum-albumin. Urine containing albumin 
may after decomposition fail to respond to the tests ; in such 
cases positive tests for albumose may be obtained. 

Haemoglobin occurs in the urine (haemoglobin uria) whenever 
there is such a destruction of red blood-corpuscles that the 
liver can not transform into bilirubin all the blood-containing 
matter set free, as in poisoning by potassium chlorate, in 
extensive burns, certain infectious diseases, malaria, haemo- 
globinuria of the newborn, etc. Whenever blood occurs in 
urine, haemoglobin is present within the corpuscles. After 
these disintegrate it will be in solution in the urine, although 
likely in modified form. 

Nueleo-albumin is inconstant in disease of the kidneys, but 
has been found frequently in cases of acute nephritis, and 
sometimes in febrile and functional albuminuria. It may be 
still present when serum-albumin and serum-globulin can no 
longer be demonstrated. 

Mixed albuminuria, in which several of the above sub- 
stances are present at the same time, is not very infrequent. 

Carbohydrates. — Glucose (dextrose, grape-sugar), C 6 H 12 6 , 
is the only important member of the group, from the clinical 
standpoint. Its presence, when persistent, indicates diabetes 
mellitus. It is frequently present in small amounts for 
short periods, as in febrile affections, alimentary disturbances, 
and dietetic errors, and is then not of serious import. 

The specific gravity of the urine is increased even higher, 
np to 1040, or in proportion to the amount of sugar present 
in spite of the large amount of water. But it is sometimes 
present even with low specific gravity if the amount of 
water is very large or the other constituents small. Other 
carbohydrates may appear along with glucose. Sugar may 
be present up to 500 grammes or even more in twenty-four 
hours. 



186 URINALYSIS. 

During the late stages of pregnancy and during lacta- 
tion, lactose in very small amount is frequently present in 
urine, but is not likely to respond to the ordinary sugar- 
tests. 

Clinically the remaining carbohydrates are of very minor 
importance; the reader interested in their chemistry is 
referred to larger text-books. 

Acetone; Diacetie Acid ; ft-oxybutyrie Acid. — These three 
substances are closely related, and are of great pathological 
importance, as their presence in diabetic urine indicates the 
possible approach of diabetic coma. Acetone appears in 
very small quantities in normal urine, the amount being so 
small, however, that special procedure is necessary to dem- 
onstrate it ; diacetie and oxybutyric acids never occur nor- 
mally. Acetone is most abundant when little albuminous 
food and no carbohydrates are eaten. It is derived from 
proteid material. Diacetie acid has practically the same sig- 
nificance as acetone, and is met with in diabetes, digestive 
disturbances, and fevers. It is now generally believed that 
/3-oxybutyric acid is the cause of diabetic coma. The amount 
of this substance excreted in twenty-four hours may be 
enormous. Siilz found in 3 cases, 65, 100, and 226 grammes 
respectively. Acetone and diacetie acid are derivative prod- 
ucts of /2-oxybutyric acid. 

Diazo Substances. — Of great practical importance is the 
detection in the urine of substances which give the Ehrlich 
diazo reaction. This test is of great clinical value in the 
diagnosis and prognosis of typhoid fever ; likewise in prog- 
nosis in pulmonary tuberculosis, since a persistent reaction 
indicates a severe case. It occurs sometimes in acute tuber- 
culosis, measles, smallpox, and scarlet fever, but seldom in 
other diseases. It occurs in a large per cent, of all typhoid 
cases, but almost never in the other diseases for which 
typhoid may be mistaken (with the exception of acute mil- 
iary tuberculosis). It may appear as early as the fifth day, 
and its disappearance usually indicates subsidence of the 
disease. A reappearance suggests a relapse. 

Bile appears in the urine in jaundice, both of the haema- 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 187 

togenous and hepatogenous varieties. Bilirubin and bile salts 
are present, the former alone being of importance. 

Blood in the urine (hematuria) results from hemorrhage 
at some point along the genito-urinary tract. Examination 
of the urine during the menstrual period is very likely to 
show blood and its various constituents unless the patient is 
catheterized. Whenever blood-corpuscles are found in urine, 
the other constituents may be assumed to be present. A 
faint albumin reaction should therefore be ascribed to this 
cause rather fhan to a kidney lesion. Hsematin, hsematoidin, 
and hsematoporphyrin are rarely present in the urine. 

Pus is found in the urine in many conditions involving 
the genito-urinary tract, such as pyelitis, pyelonephritis, 
renal and vesical stone, genito-urinary tuberculosis, cystitis, 
urethritis, rupture of an abscess into the urinary passages, 
leucorrhoea, etc. A small amount of albumin accompanies 
pus, fat, and lymph. 

Leukocytes are often present in small numbers in normal 
urine. In catarrhal and inflammatory conditions they are 
more numerous. They may be derived from the vaginal dis- 
charges. They are mostly polynuclear, and become altered 
and disintegrated by ammoniacal urine. 

Casts of the uriniferous tubules are of remarkable diag- 
nostic importance, nearly always indicating disease of the 
kidneys, though a few hyaline casts in middle life are of no 
great significance. They are cylindrical bodies, 20 to 50 ju 
in diameter, having the shape and size of small sections of 
the uriniferous tubules ; they are unbranched, usually with 
one or both ends rounded, though one end may be broken 
off sharply. Various substances enter into their composi- 
tion, giving the following classification : (a) hyaline, (6) 
epithelial, (c) granular, (d) fatty, (e) waxy, (/) leukocyte, 
(f/) blood, (ft) pseudocasts made up of bacteria or urates. 
They may be of considerable aid in the prognosis and the 
diagnosis of the variety of Bright's disease. Hyaline and 
granular casts are common to all varieties. Blood and epi- 
thelial, and especially leukocyte casts are most commonly 
seen in acute Bright's disease. Dock believes that the 



188 URINALYSIS. 

presence of enormous numbers of dark, coarsely granular 
casts is a bad prognostic sign. 

Cylindroids are hyaline bodies, longer and more slen- 
der than casts, and tapering toward a wavy point, giving 
them a w T hip-like appearance, and at times showing a coat- 
ing of granules. They are of very common occurrence, 
and at most indicate only a slight degree of renal irrita- 
tion. It is believed that they are formed in the uriniferous 
tubules. 

Spermatozoa are found in the urine after sexual inter- 
course, masturbation, or emissions, in spermatorrhoea, and 
sometimes following epileptic convulsions. They may be 
found in the urine of women after intercourse. 

Epithelium. — Very little concerning their site of origin 
can be learned from the epithelium, since the same kind lines 
the renal pelvis, ureters, and bladder. In normal urine vary- 
ing numbers of epithelial cells appear, shed from the mucous 
membrane of the urinary tract. The urine from the female 
nearly always contains numerous cells, many of them coming 
from the vagina. The cells may appear singly or in patches. 
The urine is often distinctly cloudy. 

Squamous cells — i. e. 9 pavement cells — are shed from the 
most superficial layers of the renal pelvis, ureters, bladder, 
and vagina. 

Spherical cells are much smaller than the above. They 
resemble a leukocyte somewhat, but are larger and have a 
single round nucleus. Some of them may originate from the 
renal tubules, but most of them are derived from the deeper 
layers of the renal sinus, ureters, and bladder. In large 
numbers they may indicate a catarrhal condition. 

Elongated caudate cells of varying shapes may appear 
in the urine. Their origin and significance are the same as 
those of the spherical cells. 

Tissue debris when formed in the urine may afford valu- 
able information in regard to new growths. 

Clap-threads are found floating in recently passed urine, 
even many years after a supposed cure of the gonorrhoea. 

Mucous threads are frequently found in the urine in catar- 



IMPORTANT NORMAL CONSTITUENTS OF URINE. 189 

rhal conditions, especially of the prostate, and may be en- 
tirely independent of a gonorrhoea. 

Crystals are of extremely common occurrence in normal, 
and especially in abnormal, urine. They are not, however, 
of much pathological significance, except as they indicate 
ammoniacal decomposition and excess of uric acid, when they 
suggest the possible presence of calculi. They will be con- 
sidered in detail under microscopical examination of urine. 

Amorphous debris is usually present in all urine, especially 
after standing. It is derived from broken-down cellular 
material or insoluble salts. 

Calculi. — Uric acid and urates, oxalate of lime, and earthy 
phosphates are the most common constituents of urinary cal- 
culi. Very rarely cystin, xanthin, carbonate of lime, indigo, 
and urostealith form calculi. Renal sand, uric acid, or urates 
may be passed in the urine. 

Parasites. — Vegetable and animal parasites are at times 
found in the urine. 

Vegetable parasites are much the most common, and consist 
of bacteria and rarely of fungi. 

In normal urine, freshly passed, bacteria are very seldom 
found except in small numbers. After being voided, they 
develop, as a result of contamination from outside, in enor- 
mous numbers, causing ammoniacal fermentation. 

Pathogenic bacteria, are derived mostly from local infections 
in the course of the urinary tract. Of great importance are 
gonococci in gonorrhoea, tubercle bacilli in genito-urinary 
tuberculosis, streptococci, staphylococci, colon bacilli, and 
other germs associated with the causation of cystitis and 
pyelitis. 

In some of the acute infectious diseases, such as typhoid 
fever (in particular), scarlet fever, croupous pneumonia, ery- 
sipelas, the causative germ is excreted in the urine. 

Sometimes enormous numbers of bacteria are voided in the 
urine without demonstrable cause (idiopathic bacteriuria). 

Fungi. — If found in the urine, they are nearly always due 
to contamination after the urine is voided. Saccharomycetes, 
or yeast-fungi, may be found in old urine in diabetes mellitus. 



190 URINALYSIS. 

In the United States animal parasites are almost never 
found in urine. Trichomonas, protozoa, and amoeba rarely 
appear. Trichomonas vaginalis is the most common. 

Worms are rarely found. Blood -moulds resembling earth 
worms are occasionally reported as examples of Eustrongylus 
gigas. In Egypt Schistosoma haematobium is common. 
Larval filaria and echinococcus may be found in the urine. 
Intestinal parasites are almost never found in the urine. 

Lymph occurs in the urine very rarely except in connec- 
tion with filariasis, when there is rupture of lymph-vessels 
into the urinary tract (lymphuria, chyluria). 

Fat does not occur in the normal urine. When it occurs 
in large amounts, recognizable with the naked eye, it is 
termed lipuria. Small amounts, recognized with the micro- 
scope, occur whenever there is fatty degeneration of the 
renal epithelium, pus-corpuscles, or tumor particles in the 
urinary tract. In chyluria, a tropical affection usually asso- 
ciated with filariasis, there is a large amount of fat in the 
urine, due to leakage of chyle into some part of the urinary 
tract. 

Toxins are excreted in the urine in health and disease, but 
very little is known about them. 

Foreign Matter. — Vegetable fibres, such as threads from 
towels, starch-granules from toilet powders used on the geni- 
tals, oily globules, and various forms of dirt from unclean 
receptacles, find their way into urine, and give the beginner 
trouble in microscopical examinations. 

QUESTIONS. 

What are the characteristics of normal urine? 
Upon what factors does the specific gravity of urine depend ? 
What is the reaction of normal urine and upon what does it depend ? 
What are the various colors of urine in disease? Upon what factors doen 
the color depend ? 

Mention the constituents of normal urine. 

Under what conditions is a quantitative estimation of urea of value? 

What is uric acid ? 

In what condition is uric acid increased? In what decreased ? 

In what forms is the sulphur of the urine excreted ? 

Of what significance is indican ? 

Name the different phosphates of the urine. 



EXAMINATION OF THE URINE. 191 

In what conditions are the chlorides diminished and increased? 

Of what significance is the frequent presence of calcium oxalate crystals 
in freshly voided urine ? 

Mention the pathological substances found in the urine. 

In what conditions is albumin found in the urine ? 

Of what significance is the presence of acetone, diacetic acid, and /3- 
oxybutyric acid ? 

In what diseases are diazo substances found in the urine ? 

Under what conditions are blood and pus found in the urine? 

What are casts? Of what significance are they? 

What are cylindroids, and what is their significance ? 

Mention the various cells found in urine. 

Name the pathological bacteria found in urine. 

In what conditions are lymph and fat found in the urine ? 



CHAPTER XIII. 
EXAMINATION OF THE URINE. 

It is self-evident that it is impossible for the physician to 
make complete urinary examinations according to text-book 
directions. Not only that, but it would be a great waste of 
time in the majority of cases, so far as useful, accurate clini- 
cal knowledge is concerned. This statement applies espe- 
cially to the quantitative analyses of the various solids, such 
as urea, uric acid, chlorides, sulphates, phosphates, etc. In 
the vast majority of cases such time-consuming analyses have 
thrown very little practical light on the diagnosis and treat- 
ment of cases which could not have been more easily and 
satisfactorily gained by other methods of examination. 

On the other hand, too much emphasis can not be laid 
upon the necessity of a routine examination for the chief 
abnormal constituents in every important case. 

As an example of a very sensible and useful guide in urine 
examination the following scheme, used by Professor Dock 
in his clinic, is appended. In it the essential methods for 
clinical diagnosis are considered. They may be modified in 
private practice as the physician sees fit. 



192 EXAMINATION OF THE URINE. 

Scheme for Recording Urinary Examinations. — A com- 
plete examination of a fresh sample, catheterized if neces- 
sary, should be made as soon as possible after the patient is 
seen ; also of the first twenty-four hours' urine. 

In this examination note the following points : 

Physical and Chemical Examination. — Name, Date, Quantity, 
Specific gravity, Reaction, Color, Odor, General Appearance 
(clear or turbid ; floating particles, clap-threads). 

Albumin. — Boiling and nitric acid ; ferrocyanide and acetic 
acid, Heller test if in doubt. Test for other albuminous 
bodies if indicated. 

Sugar. — Fehling. If positive, make fermentation test. 

Acetone. — Diacetic acid, /3-oxy butyric acid. 

Bile. — Foam, Gmelin's test. 

Indican. — Amount. 

Microscopical Examination. — Centrifuge a specimen for sedi- 
ment ; note amount and appearance. Record the following : 

Crystals. — Kind and amount. 

Cads. — Full description. 

Blood-corpuscles. — Condition. 

Leukocytes. — Kind. 

Pus, spermatozoa, epithelium, bacteria, protozoa, fat-glob- 
ules or crystals. 

Test for such other substances as may be suspected or 
indicated. 

In all cases of pyuria stain for tubercle bacilli and gono- 
cocci. 

In all cases of fever and neiv growths make the diazo test. 

In diabetes keep careful note of acetone, diacetic acid, and 
/9-oxybutyric acid. 

In albuminuria examine day and night urine separately. 

If the first examination is negative, note daily the quan- 
tity, specific gravity, and reaction, and make a careful exam- 
ination at once if any alteration is noted. Make a careful 
examination once a week, anyway. 

If the first examination is positive, repeat daily the com- 
plete examinations, with full notes, especially of any varia- 
tion. 



EXAMINATION OF THE URINE. 193 

Determination of Total Solids. — (1) Specific Gravity 
Method. — From the specific gravity the total amount of 
solid material in the urine can be calculated with sufficient 
accuracy for all practical purposes. Assuming the volume to 
be constant, the increase or decrease in the specific gravity 
depends entirely upon the increase or decrease in solids 
excreted ; the substances which will cause these variations 
are, of course, those which are given off in fairly large 
amounts — that is, the urea, and chlorides, sulphates, and 
phosphates ; and in pathological urine, sugar and albumin. 
An increase in uric acid, for instance, can not be great enough 
to affect the specific gravity noticeably. 

It has been found by experiment that if the last two figures 
of the specific gravity at 15° C. — that is, the figures in the 
second and third decimal places — be multiplied by 2.33 
(Trapp's or Haeser's coefficient), the product will represent 
approximately the amount of solid matter in 1 litre of urine. 
If this figure is multiplied by the number of litres in the 
twenty-four hours' urine, the total amount of solid matter 
excreted in twenty-four hours is obtained. Example : 

24 hours, urine = 2000 c.c. 

Sp. gr., =1.020. 

20 X 2.33 == 46.6. 

46.6 X 2 == 93.2 grammes. 

Results by this method agree very closely with those obtained 
by the long and tedious chemical methods. This method 
can not be used with diabetic urine. 

It is evident that such a procedure as this would not give 
a correct result unless the total twenty-four hours' urine were 
collected, measured, and the specific gravity taken, since the 
urine varies greatly in its composition at different times dur- 
ing the day. In the morning, upon rising, it has a high specific 
gravity, while after meals or after drinking much liquid the 
gravity will be very low. Absurd results will be obtained 
from the estimation of solids based upon separate portions. 

(2) By Evaporation and Weighing. — 5 c.c. of urine, accu- 
rately measured, are placed in a watch-glass containing a little 

13— C. D. 



194 EXAMINATION OF THE URINE. 

dry sand (sand and crystal having been previously weighed) : 
this is placed over a dish containing concentrated sulphu- 
ric acid, and under the receiver of an air-pump which has 
been made perfectly air-tight with vaselin. The receiver is 
exhausted ; at the end of twenty-four hours it is exhausted 
again, and the urine allowed to remain another twenty-four 
hours ; at the end of this time the crystal is weighed, the 
difference between the two weights obtained indicating the 
amount of solids in 5 c.c. of urine, from which the percent- 
age and total amount are readily calculated. 

Urea. — The quantitative estimation of urea is based upon 
the decomposition of urea into carbon dioxide and nitrogen 
by means of sodium hypobromite : 

CON 2 H 4 + 3NaOBr = 3NaBr + C0 2 + 2H 2 4- 2N. 

The carbon dioxide formed is absorbed by an excess of the 
sodium hydrate added to the hypobromite solution, while the 
nitrogen is set free and can be measured. 

Doremus Ureometer (Fig. 56). — A small amount of urine 
is poured into the smaller tube B y while the stopcock (7 is 
closed. This is then opened for a moment to allow its 
lumen to become filled, then closed. Tube A is now washed 
out with water and filled with solution of caustic soda. By 
means of a curved 1 c.c. nipple pipette add 1 c.c. of bromine, 
and a sufficient amount of water to fill the bend of the tube. 
(By this means a fresh solution of sodium hypobromite is 
formed.) Now allow 1 c.c. of urine (less if concentrated) to 
flow into the longer tube and mix with the hypobromite solu- 
tion, when brisk effervescence occurs, and the nitrogen rises 
to the top of the tube. After a short time the volume of gas 
present is read from the scale. 

The degrees marked upon the tube show the number of 
grammes or grains of urea contained in the amount of urine 
employed. This being 1 c.c, the total amount of urea is 
obtained by simply multiplying the reading of the instru- 
ment by the volume of the urine in cubic centimetres. 

This method gives fairly accurate results provided proper 
care is exercised. About a quarter of an hour should be 



EXAMINATION OF THE URINE. 



195 



allowed for the gas to collect ; after that time the gas which 
still continues to be given off will not affect the reading much. 
Since gas expands with rise in temperature, the instrument 
should not be held in the hand or placed in a warm place. 

Uric Acid. — Qualitative 
Test. — Murexid. — A small 
portion of the sediment or 
of suspected particles is 
treated with a few drops of 
nitric acid in a porcelain 
dish ; this is then carefully 
evaporated to dryness, best 
on a water-bath ; a yellowish 
spot remains if uric acid or 
xanthin is present. On ex- 
posing this spot to the vapor 
of ammonia it will assume a 
purplish color. This is due 
to the formation of ammo- 
nium purpurate (murexid). 
If it is now moistened with 
a drop of potassium hydrox- 
ide, it will become violet if 
due to uric acid. 

For the quantitative esti- 
mation of uric acid, the reader 
is referred to the larger text- 
books. The Folin modifica- 
tion of the Hopkins' method 
is recommended as being the 
simplest and the most practi- 
cable. 

Chlorides . — Qualitative 
Test. — Remove albumin from a few c.c. of urine (see p. 198). 
Acidify with several drops of nitric acid, and add a few drops 
of a 1 : 20 solution of silver nitrate. In the presence of chlo- 
rides a white precipitate of insoluble silver chloride forms 
(AgNO s + NaCl = AgCl + NaNO s ). A general idea of the 




Doremus ureometer. 



196 EXAMINATION OF THE URINE. 

quantity present may also be gained, a heavy caseous precipi- 
tate pointing to a large amount. 

For accurate quantitative tests, which the clinician will 
find of little value, the reader is referred to the larger text- 
books. 

Sulphates. — (1) Preformed Sulphates. — Test — Strongly 
acidify a few cubic centimetres of urine with acetic acid and 
treat with a few drops of barium chloride. A cloud or white 
precipitate of barium sulphate forms and indicates their 
presence. Conjugate sulphates give no precipitate, it being 
necessary first to split these into their component parts ; this 
is done by boiling with a mineral acid. 

(2) Conjugate Sulphates. — Filter the precipitate obtained 
above, after allowing it to stand for some time in order to 
have complete precipitation of the simple sulphates ; add 
several drops of hydrochloric acid and boil for some minutes, 
with the addition of a few drops more of barium chloride if 
necessary. Any precipitate or cloudiness now is caused by 
conjugate sulphates. It is well to test the filtrate with a 
little barium chloride before adding the hydrochloric acid, in 
order to be sure the simple sulphates were all removed. 

For quantitative analysis consult the larger text-books. 
The method used is exactly the same as the foregoing quali- 
tative test, carried out in a quantitative manner. 

For clinical purposes the indican test is taken as an index 
of the quantity of conjugate sulphates present. 

Phosphates. — Qualitative Test. — Ferric chloride precipi- 
tates phosphoric acid as ferric phosphate, which is insoluble 
in acetic acid. Acidify a few cubic centimetres of urine with 
a few drops of acetic acid, then add a few drops of 10 per 
cent, ferric chloride solution. A yellowish -white precipitate 
occurs in the presence of phosphates. 

Test for Earthy and Alkaline Phosphates. — Bender 10 c.c. 
of urine alkaline with ammonia ; a flocculent precipitate is 
due to the earthy phosphates. After precipitating the earthy 
phosphates as above, filter, acidify the filtrate with acetic 
acid, and test with ferric chloride as described above. 

For quantitative analysis, see larger text-books. 



EXAMINATION OF THE URINE. 197 

Under certain conditions the earthy phosphates are pre- 
cipitated from the urine on heating, and may at first sight be 
mistaken for albumin. On the addition of a drop of nitric 
acid they are dissolved and the urine clears. 

The xanthin bases, hippuric acid, creatinin, oxalic acid, 
benzoic acid, leucin, and tyrosin are of practically no clini- 
cal importance, so methods for their detection and estimation 
are intentionally omitted. 

Tests for Albumin. — The urine should be perfectly clear 
in order to test for small amounts of albumin. Turbidity 
from phosphates can be removed by adding a few drops of 
nitric acid; from urates by heating. If the turbidity is due 
to the presence of bacteria or very fine particles, it can not 
be removed by ordinary filtration through filter-paper, which 
serves the purpose in most cases. Under these circumstances 
the addition of insoluble substances, like chalk, magnesia, 
etc., to precipitate the phosphates may clarify the urine, 
which may then be filtered. The use of the Chamberland 
filter will completely clarify the urine. 

Tests for albumin are far too numerous ; they vary much 
in delicacy, some being too delicate for practical purposes, 
others not delicate enough. Only a few of those which are 
most useful will be mentioned. 

Heat and Nitric Acid. — If more than a trace of albumin is 
present, this is an extremely useful test, both qualitatively 
and quantitatively. 

A test-tube partially filled with perfectly clear urine is 
heated to boiling over a flame. A cloudiness may result, 
due to albumin or earthy phosphates. A little nitric acid is 
then added ; if the cloudiness is due to the phosphates, the 
urine immediately becomes perfectly clear, while if due to 
albumin it remains or may even be increased. 

It is necessary to bear in mind the fact that earthy phos- 
phates are liable to be precipitated by heat, this being due to 
a change in the conditions. Also that very slight amounts 
of albumin may not be precipitated by heat alone, but the 
addition of nitric acid will cause all of it to be thrown out of 
solution in the form of very fine or coarse floccules. It may 



198 EXAMINATION OF THE URINE. 

be difficult to notice any change on simple observation ; but 
by holding a tube of the urine beside the tested portion, and 
observing against a dark background for comparison, even 
an extremely faint turbidity will be easily seen ; after stand- 
ing for a few moments these floccules collect into larger ones 
and settle. Such comparison tests are often very helpful in 
other cases. 

It is necessary to have the amounts of acid and urine in 
proper proportion, since too little acid may fail to cause pre- 
cipitation, an acid albumin forming, and too much strong 
acid may redissolve the precipitate if the boiling be continued. 
Best results are obtained by adding about one-tenth to one- 
twentieth as much acid as there is urine. An idea of the 
amount of albumin may be obtained by observing the bulk 
of the precipitate ; and by always using the same amounts of 
urine and reagent, data will be given which are very useful 
for comparison. 

Acetic Acid and Heat. — Albumin may be precipitated by 
faintly acidifying the urine with acetic acid and heating. 
Unlike nitric acid, acetic acid must be used in very small 
amount, barely enough to acidify ; if more is used, an acid 
albumin forms which is not precipitated even by continued 
boiling. A single drop of glacial acetic acid may be too 
much. The addition of a cubic centimetre or so of a saturated 
solution of sodium chloride (common salt) will aid in the 
completeness of the reaction, and may be necessary with 
dilute urines. This is the best method for removing albumin 
preparatory to testing for sugar. 

If a large amount of albumin is present, it will coagulate 
and form a solid mass in the test-tube. The character of the 
precipitate should be carefully noted after the addition of 
nitric acid. According to Dock, the presence of coarse gran- 
ules indicates primary kidney disease, while that of fine 
granules indicates some cause outside of the kidneys, such as 
heart disease. 

Heller's Ring Test. — If properly applied, this is a very 
satisfactory and delicate test. The ordinary method of over- 



EXAMINATION OF THE URINE. 



199 



laying nitric acid with urine poured from a bottle is ex- 
tremely unsatisfactory, as the fluids are usually mixed. 
The following are excellent modifications of this method : 
Boston's Pipette Method. — A piece of glass tubing about 

eight or ten inches long and p IG 57 

about one-fourth to one-fifth 

inch in diameter is needed. 

With the index finger firmly 

pressed over the top of this 

tube, it is introduced into the 

urine, and by relaxing the 

pressure of the finger a small 

amount of urine is drawn up 

to the distance of about one 

inch. The tube is then placed 

under the tap and washed, and 

its outer surface is wiped dry, 

and introduced into a test- 
tube containing pure nitric 

acid, and the pressure of the 

finger again relaxed, allowing 

about as much acid to run in. 

Pressure is again applied, the 

tube removed and examined. 

There is a very sharp line of 

demarcation between the two 

liquids. If albumin is pre- 
sent, a distinct w r hite ring 

forms at the junction of the 

two liquids, increasing with 

the percentage of albumin pre- 
sent (Fig. 57). Boston's pipette method. 

The horismoscope, manufactured by Nelson, Baker & Co., 
of Detroit, is useful in making all ring tests, but is easily 
broken. In testing urine for albumin, fill the large tube 
of the instrument two-thirds full of clear urine. Then 
pour into the funnel tube 25 or 30 drops of nitric acid ; 
this will pass into the capillary tube and form a layer be- 




200 



EXAMINATION OF THE URINE. 



neath the urine. If albumin is present, a distinct white zone 
will presently appear at the point of contact, sharply defined 
against the black background, the amount of albumin being 
indicated by the density of the opaque ring. The tube 
should be free from air-bubbles before the addition of the acid. 
They can be driven out by merely tilting the instrument. A 
descriptive pamphlet accompanies the apparatus (Fig. 58). 
Simon's Modification of Heller's Test. — This is a highly use- 

Fig. 58. 




Horismoscope. 

ful qualitative test, and furnishes valuable quantitative sug- 
gestions. About 20 c.c. of urine are placed in a conical 
glass, and by means of a pipette a few cubic centimetres of 
nitric acid are carried to the bottom of the glass and allowed 
slowly to run out, by gradually lessening the pressure of the 
finger on the pipette. The last portion of acid should be 
retained in the pipette, since if allowed to dribble as the 
pipette is removed, it will cause more or less mixing (Fig. 59). 



EXAMINATION OF THE URINE. 



201 



Fig. 59. 



By carefully following these directions, the nitric acid 
forms a distinct layer beneath the urine. If albumin is pres- 
ent, a distinct white cloud will form as a ring at the junction 
of the two liquids. The extent and intensity of this ring 
vary w r ith the amount of albumin. The glass should be 
allowed to stand for some time, when a number of important 
points may be brought out. 
The same quantities of urine 
and reagent should always be 
used in each test, in order to 
draw satisfactory compari- 
sons. 

Uric acid in excess is in- 
dicated by the appearance, 
within five to ten minutes, 
of a distinct ring in the clear 
urine a little above the zone 
of contact, similar in appear- 
ance to the albumin ring. If 
this ring does not appear in 
five to ten minutes, uric acid 
is probably present in dimin- 
ished amount or the urine is 
quite dilute. The size of the 
ring indicates the extent of in- 
crease of the uric acid. In a 
urine containing more than 25 
grammes of urea to the litre, 
an appearance like hoar frost 
will be noted on the sides of 
the vessel, due to the formation of urea nitrate. With 50 
grammes and over per litre a dense mass of urea nitrate 
separates out. 

Biliary urine treated in this way, if the nitric acid con- 
tains a little nitrous acid, shows the typical color-play of 
bilirubin. 

Indican is shown by the appearance of a ring which is 
more or less violet blue, &nd situated above that referable to 




Nitric acid test. (Simon.) 



Wr-n 



\ir-U 



I 



202 EXAMINATION OF THE URINE. 

the normal urinary pigment. It varies from a light blue to 
a deep indigo-blue, depending upon the amount present. 

Potassium Ferrocyanide Test for Albumin.— This test 
is sufficiently delicate for all clinical purposes. To a few 
cubic centimetres of clear urine in a test-tube several drops 
of acetic acid are added, then a few drops of a 10 per cent. 
Fig 60 solution of potassium ferrocyanide are allowed to 
fall into the mixture ; if even a trace of albumin is 
present a distinct cloudiness ensues, and if present 
in large amount a flaky precipitate. It is best seen 
by comparing the tube, as the ferrocyanide is being 
dropped in, with another tube containing clear 
urine. If the urine is very concentrated, it should 
be diluted with distilled water. 

Occasionally the addition of acetic acid alone pro- 
duces a cloud ; this may be due to urates or urinary 
mucin (nucleoalbumin). If this happens, the urine 
should be refiltered, diluted with water, and then 
the ferrocyanide added. 

Quantitative Estimation of Albumin. — 1. As 
mentioned under the heat and nitric acid test, the 
bulk of the precipitated albumin, ^ J, J, etc., will 
give an approximation of the quantity. 

2. Esbach's Method (Fig. 60). — A special, grad- 
uated test-tube, called the albuminimeter, and Es- 
bach's reagents are required. The tube is filled to 
the U mark with the filtered urine, and then with 
albumin- the reagent to the point R. The tube is closed 
with a rubber stopper, inverted twelve times, and 
set aside for twenty-four hours. At the end of this time 
serum-albumin, serum-globulin, the albumoses, uric acid, and 
creatinin will have settled down and the amount per thou- 
sand, in grammes, can be read off from the scale. The reac- 
tion of the urine should be acid, a few drops of acetic acid 
being added if necessary, and the specific gravity should not 
exceed 1.006 or 1.008. If higher, a definite amount of dis- 
tilled water may be added and the proper calculations made. 
Tests for Albumoses. — (1) Biuret Test. — Render the cold 



EXAMINATION OF THE URINE. 203 

filtrate alkaline with a solution of sodium hydrate ; a pink 
or rose color develops on the addition of a very dilute solu- 
tion of copper sulphate, added drop by drop. 

(2) To a test-tube partially filled with cold filtered urine, 
add a few cubic centimetres of nitric acid. If a cloud 
appears, which disappears on w T arming and reappears on 
cooling, it indicates the presence of albumose. 

(3) Strongly acidify the urine with acetic acid and add an 
equal volume of a saturated solution of common salt. A 
precipitate occurring which dissolves on heating and reap- 
pears on cooling indicates albumose. To remove albumin, 
which is usually present with albumose, filter the liquid while 
hot. The albumoses are in solution in the hot filtrate and 
reappear on cooling. 

The separate recognition of serum-globulin, peptone, etc., 
is of no special clinical value. Globulin responds to the 
albumin tests exactly as albumin does ; is associated with it, 
and has the same significance. Peptone w r ill give the biuret 
test just as albumose will. Albumin and globulin will also 
give this test, though heat is required, and the color is deeper, 
more of a violet. 

Tests for Carbohydrates. — Albumin if present should 
be removed. 

Glucose Qualitative Tests. — 1. Fehling's Test.— Equal 
parts of the copper sulphate and the alkaline tartrate solu- 
tions are placed in a test-tube, diluted with 3 or 4 vol- 
umes of water, and boiled. The urine is then added, a little 
at first, and more if necessary ; not more than an equal vol- 
ume should be used. Sugar produces a precipitate of yellow 
hydroxide of copper or red cuprous oxide. The solution 
should not be boiled after the addition of the urine, only 
warmed for a moment. It must be kept in mind that 
other substances present in the urine may reduce cupric 
oxide, such as uric acid and creatinin, also though rarely 
milk-sugar, pyrocatechin, hydrochinon, and bile-pigment. 
Following the ingestion of some medicines reducing sub- 
stances also appear. These may be disregarded if care is 
taken not to boil after the addition of the urine, since the 



204 EXAMINATION OF THE URINE. 

precipitation of cuprous oxide in the presence of sugar takes 
place before the boiling-point is reached. Sometimes a slight 
reduction of Fehling's solution is caused by the uric acid ; the 
cuprous oxide is, however, held in solution by creatinin, and 
instead of a red precipitate there is a reddish or brownish 
solution. 

2. Haines's Test. — Haines's test is the best of the copper 
tests. 

Formula.— Take pure copper sulphate, 30 grains ; distilled 
water, \ ounce ; make a perfect solution and add pure 
glycerin, \ ounce; mix thoroughly and add 5 ounces of 
liquor potassse. 

Test — Take about 1 drachm of the solution and gently 
boil it in an ordinary test-tube. Next add from 6 to 8 drops 
— not more — of the suspected urine, and again gently boil. 
If sugar be present, a copious yellow or yellowish-red pre- 
cipitate is thrown down. This test solution is stable and can 
be kept indefinitely. 

3. Phenylhydrazin Test. — This is an extremely delicate 
test, perhaps five or six times more so than Fehling's, if 
made as follows : Place in a test-tube about 0.5 gramme each 
of phenylhydrazin hydrochloride and sodium acetate (about 
as much as can be placed on a 5-cent piece), fill tube one- 
third to one-half full of urine, and heat over a flame till 
the solution is clear. Remove from the flame for a moment, 
then bring to a boil again, and repeat three times, removing 
the tube from the flame between times. Set aside to cool, 
being careful not to disturb the formation of crystals by 
shaking. (With sugar phenylhydrazin forms an insoluble 
crystalline compound, phenylglucosazon.) Examine in about 
fifteen minutes. With a pipette transfer some of the crys- 
tals to a slide, cover with a cover-glass, and examine under 
the microscope. If present, these crystals appear as delicate 
bright-yellow needles arranged in bundles and sheaves. 

To illustrate the delicacy of this test, a 4 per cent, sugar 
urine was diluted 120 times, and gave the test. The same 
urine diluted 20 times failed to give the Fehling test. 

Quantitative Sugar Tests. — (1) Fermentation Test. — 



EXAMINATION OF TEE VRINE. 205 

With yeast, sugar undergoes fermentation, with the forma- 
tion of alcohol and carbonic acid. The specific gravity of 
the urine is lowered by this process, and upon this fact is 
based the quantitative estimation. Two 6-ounce bottles are 
filled two-thirds with urine ; to one a fourth of a cake of 
fresh Fleischmann's yeast is added/ in small pieces. Noth- 
ing is added to the other. Both are corked to prevent con- 
tamination, a slit being cut in the cork of bottle No. 1 to 
allow the gas to escape. Great care must be taken not to 
contaminate No. 2. The bottles are set aside in a warm room 
for twenty-four hours ; at the end of this time No. 1 is tested 
for sugar with Fehling's solution ; if there is no reaction, the 
urine is filtered and the specific gravity very carefully taken. 
The specific gravity of No. 2 is also taken at the same time, 
and the specific gravity of No. 1 subtracted from it. The 
figure obtained is multiplied by Robert's factor, 0.230, the 
product resulting representing the percentage of sugar. 

Example. — Specific gravity before fermentation, 1040 
Specific gravity after fermentation, 1020 

~20 
20 X 0.230 = 4.60 per cent. 

For a very accurate estimation of the specific gravity, 
Lohnstein's urinometer should be used, reading to the fourth 
place. 

The saccharimeter of Einhorn or Lohnstein may be em- 
ployed. Either is extremely handy and fairly accurate. The 
percentage of sugar corresponding to the displacement of 
urine by gas can be read oif the instrument directly. The 
objection to the fermentation test is that it requires a wait 
of twenty-four hours or longer for its completion (Fig. 61). 

(2) Purdy's Modification of the Pavy Method. — This is by 
all means the most practical method of estimating the per- 
centage of sugar. The quantitative estimation of sugar by 
the Fehling method is so time-consuming and the end-reac- 
tion so uncertain that in the hands of most physicians it is 
extremely unsatisfactory. 



206 



EXAMINATION OF THE URINE. 
Fig. 61. 




H 



Einhorn's saccharimeter. (Simon.) 



To demonstrate the simplicity and accuracy of Purdy's 
method, a series of sugar estimations, by all three methods — 
i. e., Fehling, Purdy, and fermentation — was carried out in 
the clinical laboratory of the University of Michigan on a 
diabetic urine, by Dr. Cleaves, with the following results : 



July. 


Fehling. 


Purdy. 


Fermentation. 


Quantity. 




Per cent. 


Grammes 


Per cent. 


Grammes 


Per cent. 


Grammes 


c.c. 


12 


1.50 


13.90 


1.43 


13.23 


. , 


. , 


925 


13 


1.40 


14.97 


1.30 


13.32 


1.38 


14.83 


1075 


14 


0.89 


5.78 


0.87 


5.56 


0.92 


5.98 


650 


15 


1.47 


14.41 


1.48 


14.43 


1.51 


14.72 


975 


16 


1.13 


8.27 


1.11 


8.32 


1.15 


8.62 


750 


17 


1.16 


10.15 


1.18 


10.32 


1.15 


10.06 


875 



From the above figures it can be seen that the results with 
Purdy's method approach very closely those obtained by the 



EXAMINATION OF THE URINE. 207 

Fehling and the fermentation methods. Purdy's method is 
based on the fact that a definite amount of sugar will cause 
the complete reduction of a definite amount of the reagent, 
the latter being of a certain prescribed strength. The cupric 
oxide is reduced to cuprous, and this, instead of being pre- 
cipitated as a red granular precipitate, is held in "solution by 
the ammonia of the reagent, giving at the end a perfectly 
clear, colorless liquid. The end-point is thus very easily de- 
termined. The reagent is of such strength that exactly 35 c.c. 
will be just reduced completely by 0.020 gramme of sugar. 

Technic of Purdy's Method. — Place 35 c.c. of the reagent 
in a flask of 150-200 c.c. capacity, add about 2 volumes of 
water, and bring the contents to the boiling-point. Run the 
urine from a burette into the boiling copper solution, drop 
by drop, until the blue color begins to fade ; then still more 
slowly, three to five seconds elapsing after each drop, until the 
blue color just completely disappears, and leaves the solution 
perfectly transparent and colorless. The number of cubic 
centimetres of urine required to decolorize the 35 c.c. of the re- 
agent contain exactly 20 milligrammes (0.02 gramme) of sugar. 

Example. — If it require 2 c.c. of urine to reduce 35 c.c. of 
the test-solution, there is present 1 per cent, of sugar ; if it 
require 4 c.c, there is present 0.5 per cent, of sugar. The 
total quantity of sugar excreted in twenty-four hours can 
easily be calculated. Suppose 2000 c.c. of urine are excreted, 
and 2 c.c. reduce the copper, 2 c.c. = 0.020. 2000 c.c. = 
1000 X 0.020, or 20 grammes in twenty-four hours. 

Precautions for Purdy's Technic. — It will be noticed after the 
determination that upon standing for some time the contents 
of the flask slowly assume the blue color again. This is due 
to reoxidation, which is somewhat rapid, and should not be 
mistaken for imperfect reduction or defect in manipulation. 

The best results are obtained by first diluting the urine 
before the titration if the amount of sugar is large. The 
diluted urine should contain about 1 per cent, of sugar, and 
the calculation is made according to the dilution. 

Polariscopic Methods. — By means of the polariscope the 
percentage of sugar can be estimated ; and also the kind of 



208 EXAMINATION OF THE URINE. 

sugar can be determined. For the use of the instrument the 
reader is referred to special books. 

Tests for Acetone in the Urine.— Legal's Test. — To a few 
cubic centimetres of urine in a test-tube add a crystal of sodium 
nitroprusside, render alkaline with sodium or potassium hy- 
droxide, and shake till it is dissolved. The dark-red color 
produced may be due to creatinin or to acetone. The addition 
of a few drops of acetic acid changes this to a wine-red color if 
acetone is present; if absent, the color changes to a yellow. 
This test may also be used for creatinin, the change from red 
to yellow on the addition of acetic acid being characteristic. 

Lieben's Test. — Phosphoric acid is added to the urine, about 
1 gramme to the litre ; 500 to 1000 c.c. of this are distilled, 
only 10 to 15 c.c. being distilled over. To this add a few- 
drops of potassium or sodium hydroxide and enough of dilute 
LugoPs solution to give a yellowish color, then sodium 
hydroxide till the color just fades. If acetone is present, a 
yellow precipitate of iodoform appears, which is recognizable 
by its odor on heating, and by the form of the crystals, very 
small six-sided plates or stars. 

Diacetic or Acetoacetic Acid in the Urine. — Gerhardt's 
Test. — A few cubic centimetres of urine are treated with a 
strong solution of ferric chloride, added drop by drop. If a 
precipitate of phosphates occurs, this is filtered off and more 
iron added to the filtrate. A wine-red color indicates the 
presence of diacetic acid. A second portion of the urine is 
boiled and similarly treated. If the reaction occurs after 
the urine has been boiled, it is not due to diacetic acid. 

If in the second urine no reaction is obtained, a third por- 
tion is acidulated with sulphuric acid and extracted with 
ether. The ethereal extract when treated with ferric chloride 
solution gives a wine-red color, which disappears on standing 
for twenty-four to forty-eight hours, if diacetic acid is pres- 
ent, especially if acetone is abundant. 

Salicylates in the urine give a similar reaction on the addi- 
tion of ferric chloride, but the color is permanent, while that 
due to diacetic acid gradually fades. Diacetic acid is readily 
changed to acetone by heating, or even by standing. 



EXAMINATION OF THE URINE. 209 

ft-oxybutyric Acid. — If after fermentation of the sugar the 
urine rotates the plane of polarized light to the left, /^-oxy- 
butyria acid is present. Such rotation, before fermentation, 
may be caused by lsevulose. 

Tests for Bile in the Urine. — Bilirubin is the only bile- 
pigment met with in fresh urine. It is never found in nor- 
mal urine, so is an infallible sign of disease. 

Foam Test. — This is a very satisfactory method of demon- 
strating the presence of bile. A few cubic centimetres of 
urine in a test-tube are shaken vigorously ; if bile is present, 
the foam takes on a greenish or greenish-yellow T iridescence, 
and is quite permanent. 

Morphological elements, casts, etc., are stained by the 
bilirubin, and appear yellow under the microscope. 

Gmelin's Test. — Make a ring-test just as in making the 
Heller test for albumin, using concentrated nitric acid which 
contains some nitrous acid fumes. If bilirubin is present a 
band of colored rings appears just above the point of contact 
of the two liquids, exhibiting the colors of the rainbow. 
The green is the most characteristic and important, especially 
when taken in conjunction with the pink. These colors 
are caused by the oxidation of bilirubin through a series of 
products ; the green is due to biliverdin, and represents the 
first product, it is therefore nearest the oxidizing agent. The 
nitric acid can be prepared by simply allowing it to stand 
exposed to sunlight until it becomes colored yellow. 

Rosenbach's Modification of Gmelin's Test. — Filter the 
urine through thick filter-paper ; unfold the filter and place 
a drop or so of concentrated nitric acid, which contains some 
nitrous, upon its inner surface. If bilirubin is present, the 
typical rings are produced, the green being the most typical 
and important. 

Iodine Test. — Pour 1 c.c. of tincture of iodine, diluted with 
8 parts of alcohol, on the surface of the urine in a test-tube. 
A green ring at the point of contact of the two liquids shows 
the presence of bile. 

Tests for Indican in the Urine. — Jaffa's Test. — Bliss has 
modified this test by using the official solution of ferric 
14— c. D. 



210 EXAMINATION OF THE URINE 

chloride, instead of the solution of calcium hypochlorite, which 
spoils very quickly. To a few cubic centimetres of urine in a 
test-tube add an equal volume of concentrated hydrochloric 
acid, 2 or 3 drops of ferric chloride or hypochlorite solu- 
tion, and 3 or 4 c.c. of chloroform. Shake thoroughly but 
not vigorously, and set aside. Indoxyl is set free, and is 
oxidized to indigo-blue, which is taken up by the chloro- 
form ; this settles to the bottom of the tube. The intensity 
of the blue color depends on the amount of indican pres- 
ent. Albumin does not interfere with the reaction. Bile- 
pigments interfere with the reaction, and must be removed 
by careful addition of a solution of lead subacetate. Potas- 
sium iodide, because of the liberation of iodine, colors the 
chloroform more or less violet. It is well to have marked 
test-tubes, and to use the same amounts of urine and reagents 
each time, and thus become familiar with the comparative 
colors in different urines. 

This test can be made quantitative by comparing with a 
set of tubes of a chloroform solution of indigo-blue of known 
strengths ; the volumes of solution must, of course, be the 
same in all. 

Diazo Reaction of Ehrlich. — For method of preparing 
the reagent (see page 186). To 5 c.c. of sulphanilic acid solu- 
tion add 2 drops of sodium nitrite solution ; this gives a 
mixture of about 40 : 1. To this mixture add an equal vol- 
ume of urine, and mix carefully by reversing the test-tube 
several times. Now add about 2 c.c. of ammonia, letting it 
run down the side of the test-tube. At the point of contact 
of the ammonia and the mixture rings of various tints form, 
ranging from light yellow, through dark yellow, orange and 
brown, to eosin or garnet, depending upon the urine. The 
formation of a red ring is an indispensable part of the true 
Ehrlich diazo reaction. It is also essential that, on shaking, 
the foam takes on a pink color. This color varies consider- 
ably in intensity, depending on the strength of the reaction, 
from the palest rose to the deepest pink, but must not be any 
other color, such as salmon, orange, etc. The foam is also 
persistent. 



EXAMINATION OF THE URINE. 211 

Tests for Blood in the Urine. — The color of the urine 
suggests its presence, and may vary from " smoky " when 
little blood is present, to red or brown. The sediment may 
be reddish if the corpuscles settle. The hsemin crystal and 
guaiacum tests may be applied (see page 21). The presence 
of red blood-corpuscles under the microscope is pathogno- 
monic. Albumin, white cells, and haemoglobin can always 
be demonstrated in the presence of blood. For recognition 
of red cells (see page 31). In alkaline urine the corpuscles 
disintegrate rapidly, and may not be demonstrable after 
ammoniacal fermentation has begun. 

Fat in the Urine is most readily detected by the micro- 
scope (see page 190). If necessary, the specimen may be 
treated with Sudan III. This solution has an affinity for fat 
only, staining it red, and leaving everything else unstained. 
Specimens must not be treated with alcohol or ether, since 
the fat would be dissolved out. A drop of the solution is 
allowed to run under the cover-glass preparation ; under the 
microscope the neutral fat-particles are seen to take on a red 
color. 

Fat may be removed from urine by shaking with ether, 
removing the ethereal layer after it has risen, and evaporat- 
ing. The fat may then be subjected to chemical tests. 

Pancreatic Urine Test. — The diagnosis of diseases of the 
pancreas has assumed such importance in medicine and 
surgery of late years, and it is such a difficult field of diag- 
nosis, that a trustworthy urinary test would be welcomed 
with open arms. Cam midge, working in conjunction with 
Mayo Robson, has introduced the following test : Sufficient 
work has not as yet been done w T ith the reaction to prove its 
value in pancreatic diagnosis. However, it is to be hoped 
that it will prove to be all that its author claims for it. 

Pancreatic Reaction. — Cammidge describes the procedure 
in which he calls reaction "A" as follows : 

The specimen of urine to be examined is filtered, and 10 
c.c. of the filtrate are poured into a small flask. One cubic 
centimetre of strong hydrochloric acid is added and, a funnel 
having been placed in the neck to act as a condenser, the flask 



212 EXAMINATION OF THE URINE. 

is placed on a sand bath and gently boiled for ten minutes 
after the first sign of ebullition is detected. A mixture of 
5 c.c. of the filtered urine and 5 c.c. of distilled water is then 
poured into the flask, which is afterward cooled in running 
water. The excess of acid is now neutralized by slowly adding 
4 grammes of lead carbonate and, after standing for a few 
minutes to allow of the completion of the reaction, the urine 
is filtered through a moistened filter-paper and the flask is 
washed out with 5 c.c. of distilled water on to the filter. To 
the clear filtrate are now added 2 grammes of powdered sodium 
acetate and 0.75 gramme of phenylhydrazin hydrochlorate, 
and the mixture is boiled for from three to four minutes on the 
sand bath. The hot fluid is then poured into a test-tube and 
allowed to cool undisturbed. After the lapse of a period, vary- 
ing with the severity of the case from one to twenty-four 
hours, a more or less abundant flocculent yellow deposit is 
found at the bottom of the tube, and this when examined under 
the microscope with a ^-inch objective is seen to consist of 
sheaves and rosettes of golden-yellow crystals. As the pres- 
ence of sugar in the urine would obviously vitiate the results 
thus obtained, it is necessary before proceeding to the test to 
make sure that the untreated urine does not give a reac- 
tion with phenylhydrazin. This may roughly be done with 
Fehling's solution, or some similar test, but it is better to carry 
out a control experiment with phenylhydrazin hydrochlorate 
and sodium acetate in the manner I have just described, omit- 
ting the preliminary boiling with hydrochloric acid. Should 
the control experiment reveal even a trace of sugar, it must 
be removed by fermentation, with subsequent boiling to expel 
the alcohol formed, before the investigation is proceeded with. 
The presence of albumin in the urine is also liable to cause 
trouble, and it is best got rid of either by treatment with 
ammonium sulphate or by acidifying with acetic acid, heating 
and filtering. The results obtained by this method were found 
not to be absolutely trustworthy, although a useful aid in 
diagnosis, since a positive reaction was also obtained in patients 
suffering from certain other diseases where active tissue-change 
was taking place, such as cancer, adenitis, pneumonia, etc. 



EXAMINATION OF THE URINE. 213 

For a long time the positive reaction given by these non-pan- 
creatic cases diminished the practical usefulness of the test, 
but eventually a means by which the cases of pancreatitis 
might be distinguished was devised, and we now believe 
that, by combining the results of the two, it is possible in 
the large majority of cases to make a trustworthy diagnosis 
from the examination of the urine alone. The differentiating 
test depends on the fact that the formation of the crystals 
described in reaction " A" is interfered with in inflammation 
of the pancreas by a preliminary treatment of the urine with 
perchloride of mercury, while such treatment does not affect 
the appearance of crystals in cases of cancer of the pancreas 
and the other conditions which give rise to a positive reaction. 
The procedure, which I shall refer to as the u B" reaction, is 
as follows : Twenty cubic centimetres of the filtered urine are 
thoroughly mixed with half its bulk of a saturated solution of 
perchloride of mercury. After standing for a few minutes it 
is carefully filtered, and to 10 c.c. of the filtrate 1 c.c. of strong 
hydrochloric acid is added. The mixture is then boiled for ten 
minutes on a sand bath and subsequently diluted with 5 c.c. of 
filtrate from the mixed urine and perchloride of mercury 
solution and 10 c.c. of distilled water. After cooling it is 
neutralized with 4 grammes of lead carbonate and the suc- 
ceeding stages of the operation are carried out as in reac- 
tion " A." 

Experiments were then set on foot to still further differ- 
entiate the forms of disease, and a careful observation of the 
crystals isolated from the urines of various types of pan- 
creatic disease showed that while there is a general resem- 
blance, certain variations occurred and the differing rate of 
solubility of crystals in dilute sulphuric acid was remarked 
and found to be of still greater value. If the crystals obtained 
in reaction "A". are observed under the microscope while a 
1 : 3 dilution of sulphuric acid is being irrigated under the 
cover-glass, they will be seen to turn brown when the acid 
reaches them and dissolve. In acute pancreatitis the interval 
that elapses between the first appearance of the brown color 
and complete solution varies from a few seconds to one-half or 



214 EXAMINATION OF THE URINE. 

three-quarters of a minute. In chronic pancreatitis it extends 
from half to one and a half or, rarely, to two minutes, while 
in malignant disease the crystals do not completely disappear 
until three to six minutes. The practical results of the 
examination of the urine he summarizes as follows : 

1 . If no crystals are found by either the " A" or "B" method 
the pancreas is not at fault, and some other explanation of the 
symptoms ought to be sought. 2. If crystals are obtained by 
the "A" method, but not by the "B" reaction, active inflam- 
mation of the pancreas is present, and surgical interference is 
generally indicated, (a) The crystals obtained by the " A" 
method will in acute inflammation dissolve in 33 per cent, 
sulphuric acid in about half a minute, (b) In chronic inflam- 
mation the crystals obtained by the "A" method will take one 
or two minutes to disappear. 3. If crystals are found in prep- 
arations made by both the "A" and the U B" methods there 
may be (a) malignant disease of the pancreas, when the crys- 
tals will, as a rule, take from three to five minutes to dissolve, 
and operation is inadvisable ; (6) a damaged pancreas, due to 
past pancreatitis, when the crystals will dissolve in from one 
to two minutes ; (c) some disease not connected with the pan- 
creas, when the crystals dissolve in about one minute. In 
the latter, two (6) and (c), the urgency of the symptoms and 
the condition of the patient must decide the need for an 
exploratory incision, but there is generally not much difficulty 
in referring the case to one or other of the groups when the 
clinical history is considered in conjunction w r ith the result of 
the examination of the urine. 



QUESTIONS. 

Give scheme for urinary examinations. 

What is Trapp's method for the determination of total solids ? 

Describe a quick method for the quantitative determination of urea. 

What is the murexid test for uric acid ? 

Describe a qualitative test for chlorides. 

What is meant by conjugate sulphates f 

Describe a qualitative test for phosphates. 

Describe the Boston pipette method of testing for albumin. 

Describe Simon's modification of Heller's test. 

Describe the potassium ferrocyanide test for albumin. 



URINARY SEDIMENTS, 215 

Describe the volume method of quantitatively estimating albumin. 
Describe Esbach's method. 
Mention several tests for albumose. 
What is Fehling's test for sugar? Haines' test ? 
Describe Purdy's method of quantitatively estimating sugar. 
Describe Legal's test. Lieben's test. 
Describe Gerhardt's test. 

How are salicylates in the urine distinguished from diacetic acid in the 
urine ? 

Describe Gmelin's test. Also the foam test for bile. 
Describe Jafle's test for indican. 
Describe the diazo-reaction of Ehrlich. 
Of what value is cryoscopy in urinalysis? 



CHAPTER XIV. 
UEINAEY SEDIMENTS. 

Macroscopical Examination. — Normal urine on standing 
for some time gradually deposits a faint white cloud occupy- 
ing the lower part of the vessel, and made up of mucus, 
a few epithelial cells and mucous corpuscles. A dense sedi- 
ment of amorphous urates is common, especially in cold 
weather, and varies in color from almost white to pink or 
brown; this is the so-called "brick-dust" deposit; it disap- 
pears on warming the urine or on the addition of caustic 
alkali. Uric acid is often deposited from very acid, highly 
colored urines, in the form of small grains looking like red 
pepper; it can be demonstrated by the murexid test or its 
solubility in caustic alkali. A voluminous white sediment usu- 
ally means earthy phosphates, though it may have ammonium 
urate, triple phosphate, or pus with it, or it may be pure pus. 
This, however, is usually shiny or sticky, while the phosphate 
sediment is light and fluffy ; such urines are usually alkaline. 

A yellowish-white sediment may consist of pus ; if the 
urine is acid, it is separated into small freely moving par- 
ticles ; but if alkaline, it consists of a viscid, stringy, cohe- 
rent mass. 



216 URINARY SEDIMENTS. 

A chocolate-brown sediment usually indicates the presence 
of blood in the urine ; clots of blood may come from the 
kidney, ureter, bladder, or urethra, and may at times resem- 
ble worms. 

Microscopical Examination. — The microscopical exami- 
nation of urinary sediments is a very important part of urine 
analysis, and very frequently throws much light on both 
diagnosis and prognosis. 

The freshly passed urine is sedimented by means of the 
centrifuge or by standing for several hours in a conical 
vessel, covered to keep out dust. The first method is 
preferable, as it requires only two or three minutes; if 
the latter method be used, certain changes may take place in 
the urine during the long wait, modifying the sediment, and 
thus incorrect conclusions may be drawn regarding it. 

In the freshly passed urine small floating particles or 
mucous threads, technically termed " floaters," may be seen. 
These may be fished out by means of a glass tube and exam- 
ined separately. Special attention should be given to these 
mucous threads, the so-called " clap-threads," and to the 
minute opaque cheesy bits; the former should be stained and 
examined for gonococci, the latter for tubercle bacilli. These 
particles can be obtained by the following method : With the 
index-finger pressed firmly over the top, a pipette or glass 
tube is brought near the particles, pressure is then slightly 
relaxed and the particles drawn up into the tube ; pressure 
is increased again, the tube withdrawn and held for a moment 
to allow settling, and then they are deposited on a slide 
or cover-slip ; excess of urine is removed with a strip of 
filter-paper. The specimen is then dried, stained, and exam- 
ined. After the urine is sedimented specimens are trans- 
ferred to a slide in exactly the same way as just described 
for floating particles, and examined with the microscope. 
The specimens should not be covered with a cover-slip, and 
a low power should be used ; furthermore, the light should 
be fairly well shut off. When in doubt as to the recognition 
of certain of the smaller elements, as blood-corpuscles, etc., 
or when desiring to study their finer structure, a cover-slip 



V BINARY SEDIMENTS. 
Fig. 62. 



217 




Extraneous matters found in urine : a, cotton-fibres ; 6, flax-fibres ; c, hairs ; d, air- 
bubbles; e, oil-globules; /, wheat-starch : g, potato-starch ; /*, rice-starch granules; 
i, i, i, vegetable tissue ; k, muscular tissue ; I, feathers. 

should be applied and a higher power used. For the recog- 
nition of bacteria it may be necessary to prepare the speci- 
men, dry, fix, and stain it, as with sputum. 

Specimens of sediment must always be examined while 



218 URINARY SEDIMENTS. 

still wet, since as the water evaporates all the solid constitu- 
ents of the urine will be left in crystalline or amorphous 
form covering everything else. For this reason it is well to 
prepare one at a time ; and if the examination is to be pro- 
longed, hanging-drop preparations, as made in bacteriological 
examinations, will be found very convenient. (See under 
Widal Reaction.) On the other hand, too much fluid will 
be liable to run off the slide on to the stage of the instru- 
ment. Excess of urine can easily be removed with a strip 
of filter-paper. 

It is frequently desirable to treat a specimen of sediment 
with a reagent and notice the effect under the microscope. 
The common way of adding the reagent to the edge of the 
cover-slip and allowing it to flow under will usually result 
unsatisfactorily ; some of the reagent is almost certain to get 
on top of the slip, and may get on the objective. A much 
better plan is to place a small drop of the concentrated sedi- 
ment and a drop of the reagent side by side on the slide, 
allow them to run together, and cover if necessary. Such a 
preparation is much neater and there is no danger of injur- 
ing the microscope. 

Classification of Urinary Sediments. — 

Chemical, or Unorganized < A ^ s , me * 

1 Amorphous. 

r Formed elements, as blood-cor- 
puscles ; pus-cells ; epithe- 
lium ; casts ; cylindroids ; 

A , ^ , spermatozoa. 

Anatomical, or Organized < -r> r ., • i i . i i 

.Parasites, animal and vegetable. 

Foreign bodies ; fragments of 
tissue ; clap-threads ; blood- 
clots, etc. 

Chemical Sediments. — These, as a rule, are of little diag- 
nostic or prognostic value. Most of the substances entering 
into their formation occur in solution in normal urine ; but 
as a result of changes from normal conditions to abnormal, 
or in some cases to slightly different but still normal condi- 
tions, they are rendered insoluble, and so appear as a seai- 



URINARY SEDIMENTS. 219 

ment. Such changes, which may at times be considered as 
pathological, and at other times as simply due to alteration 
in diet, habits, etc., are hyperacidity of the urine ; decrease 
in acidity or even change to alkaline ; increase in the amount 
of a normal constituent above the usual amount ; decrease in 
the volume of the urine, rendering it more concentrated, and 
thus relatively increasing the amounts of the substances in 
solution ; the occurrence of certain substances as a result of 
eating certain articles of food ; development of ammonia. 
This last is always pathological if occurring before the urine 
is passed, and is always to be expected in urine which is 
kept for some time. 

Some of the substances found in chemical sediments always 
occur in crystalline form ; some always are amorphous ; a 
few may take either form, but usually the crystalline. A 
few are rare, and need practically no consideration ; these are 
cystin, xanthin, cholesterin, leucin, and ty rosin. These 
always occur as crystals when found in the sediment ; but 
they may remain in solution. The first three are of interest, 
since they have been found in calculi. If there is reason to 
suspect their presence, the reader should consult large books 
for methods of identification and tests. 

The commonly occurring sediments are composed of uric 
acid and urates ; the various phosphates ; oxalate and car- 
bonate of lime. Sulphate of lime and hippuric acid are rare, 
their solubility precluding their deposition except in very 
concentrated urine. Fat or oil in the form of globules, or 
crystals, of fatty acids and soaps, are not common except as 
accidental constituents. Certain coloring-matters, such as 
hsematoidin, bilirubin, indigo, etc., are also very rare, though 
indigo is frequently seen in the sediment of old decomposed 
urines. 

If the following facts be borne in mind, the identification 
of a sediment will not be a difficult matter. A sediment is 
composed only of such substances as are insoluble in the urine 
under the existing conditions of concentration, reaction, etc. ; 
none of the substances is absolutely insoluble, though some 
are practically so ; a sediment therefore represents the excess 



220 UEINA R Y SEDIMENTS. 

over the amount that can be held dissolved. Whenever, by 
any change in the conditions or by any combination of cir- 
cumstances, an insoluble compound can form, the tendency 
will be for it to form ; the equilibrium existing between the 
substances in the solution is thus destroyed and the reaction 
will continue until equilibrium is again restored. Certain 
new chemical compounds may thus be formed. 

Substances which crystallize will always take a certain 
definite form when possible ; but various causes may inter- 
fere, and instead of well-developed, perfect crystals, there 
will be more or less imperfect forms, or even an amorphous 
deposit ; often the crystals will show the tendency toward the 
normal form. When crystals are being deposited slowly they 
will grow; triple phosphate, for instance, will appear as very 
small well-formed crystals at first, but if examined a few 
days later, after th§ ammoniacal fermentation has progressed 
further, the crystals will be much larger, and may even 
be large enough to be recognized with the naked eye. The 
influences which modify crystal formation are especially the 
rate and the presence of other substances. As a rule, the 
slower the formation, the more perfect the form ; and the rate 
may be retarded by slow cooling, slow evaporation, etc. 
Triple phosphate may be used again as an illustration : if 
ammonia is produced in the urine by bacteria, and thus 
slowly, the triple phosphate will appear in almost perfect 
form ; if, however, ammonia be added to the urine directly, 
the triple phosphate is formed at once and precipitated ; no 
time is given for the characteristic form to be taken, and 
fern-leaf-shaped or star-shaped crystals will be seen. Ammo- 
nium urate, if made by adding ammonia to a solution of uric 
acid, nothing else being present, will consist of needles; but 
as found in a urinary sediment, it is almost always in the 
form of small more or less highly colored, balls ; the other 
constituents of the urine prevent it from taking the needle- 
shape ; the small spicules so frequently seen show the ten- 
dency toward needles ; and sometimes a burr-like mass of 
crystals can be observed. 

Some substances on being deposited from urine, or from 



URINARY SEDIMENTS. 



221 



other solutions also, will enclose and drag down suspended 
particles or coloring-matter ; for example, uric acid deposited 
from urine is almost invariably colored, the more deeply the 
more intense the color of the urine ; on the other hand, friple 
phosphate and calcium oxalate are never colored, but are 
bright and shining. A familiar illustration of an analogous 
process is the clarification of water by means of alum, the 
bulky, voluminous precipitate of aluminum hydrate, in set- 
tling, acting as a drag-net, will carry down suspended parti- 
cles, bacteria, etc. This process may be used in clarifying 
urine which will not filter clear. 



Fig. 63. 




Uric-acid crystals of various shapes. 

Uric Acid. — Uric acid itself has a very slight solubility ; 
it forms two kinds of salts, acid and normal. Sodium acid 
urate, C-H 8 NaN 4 3 , maybe taken as the type of the former ; 
and C 5 H 2 Na 2 N 4 3 the latter. The constituents of normal 
urine increase the solubility of these difficultly soluble forms, 
holding them as the normal urates, which are easily soluble, 
and they do not therefore appear as sediment in fresh urine. 
The acid salts also have very slight solubility. It is as 
normal salts that uric acid exists in urine ; by a change in the 
conditions, excess in the amount, the degree of acidity, lower- 
ing of the temperature, etc., there is a change to the more 



222 



URINARY SEDIMENTS. 



insoluble form, either the acid urate or uric acid, and the 
appearance of a sediment. This frequently occurs in cold 
weather as a result of simple cooling. Uric acid crystals are 
almost always colored either a deep yellow or brownish red. 
or even brown, rarely a pale yellow. The rhombic prism is 
the essential form of the crystal, but it may present all sorts 
of modifications of this form, star-shaped and fan-shaped 
clusters. Colored crystals occurring in acid urine are in all 
probability uric acid. 

Urates. — As explained above, urates are very frequently 
deposited as a result of cooling of the urine ; an interchange 



Fig. 64. 



Fig. 65. 





Sodium urate : a, a, from a gouty con- 
cretion ; b, b, artificially prepared by add- 
ing liquor sodse to the amorphous urate 
deposit. (Roberts.) 



Ammonium urate spontaneously 
deposited: a, spheres and globular 
masses ; b, dumb-bells, crosses, rosettes, 
(Roberts.) 



takes place between the normal urate and the acid phosphate, 
with formation of the acid urate and alkaline or secondary 
phosphate. The acid urate is thus precipitated. The same 
reaction may go farther and form uric acid. The urates are 
chiefly those of sodium and potassium, sometimes also of 
calcium and magnesium ; they are spoken of as the amor- 
phous, or acid, or mixed urates, or brick-dust deposit. 
Ammonium urate, as stated, will appear only when there is 
ammonia. The urates rarely appear in crystalline form, 
though sometimes small needles are found. The usual form 
is a rather dense, sandy deposit, cream-colored, yellow, pink 



UMINARY SEDIMENTS. 



223 



or rose-colored, or even brown, depending upon the color of 
the urine. Under the microscope small sandy particles are 
seen, usually yellowish or brownish, with now and then a 
crystal of uric acid. If there should be any doubt, the fol- 
lowing very simple characteristic tests can be applied : 

(a) A drop of caustic soda or potash added to the sedi- 
ment on the slide will cause it to dissolve immediately, (b) 
A drop of hydrochloric acid added to the sediment will in 
two or three minutes produce numerous very small colorless 

Fig. 66. 




Ammonium urate. (Musser.) 



crystals of uric acid, (c) Simply warming some of the urine 
in a test-tube will cause a solution of the deposit and clear- 
ing-up of the urine (Figs. 64 and 65). 

Calcium Oxalate. — Calcium oxalate is usually found in 
acid urine, frequently associated with uric acid or urates ; but 
occasionally in alkaline urine, and at times associated with 
triple phosphate. It is almost always in the form of small 
colorless shining octahedra, the so-called envelope crystals ; 
these have the appearance of small squares with lines con- 



224 



URINARY SEDIMENTS. 



necting the corners and crossing at the middle. It rarely 
occurs as small dumb-bells, ovals, or amorphous (Fig. 67). 



Fig. 67. 




Calcium oxalate crystals. 



The solubility in hydrochloric acid and insolubility in 
acetic acid or caustic alkali may aid in identifying it. 



Fig. 68. 




Various forms of triple phosphates. (Finlayson.) 



Phosphates. — Whenever the urine becomes alkaline from 
any cause, the phosphates of calcium and magnesium, 
Ca 3 (P0 4 ) 2 and Mg 3 (P0 4 ) 2 , may be expected ; if ammonia is 



URINARY SEDIMENTS. 225 

present, ammonium magnesium phosphate, NH 4 MgP0 4 , or 
triple phosphate will also appear. In urine which is very 
faintly acid these may be found, as explained, or rarely the 
acid phosphate of calcium, CaHP0 4 . 

The first named, earthy or amorphous phosphates, occur as 
a very voluminous, colorless, fluffy deposit, hardly visible 
under the microscope. 

Triple phosphate occurs almost invariably as the so-called 
" coffin-lid " crystals, colorless prisms ; rarely as fern-leaf- 
shaped or in stars of leaf-shaped crystals, and these only 
when ammonia has been added to the urine or has developed 
very rapidly (Fig. 68). The acid phosphate of calcium forms 
colorless wedge-shaped crystals, often in bundles (Fig. 69). 

Fig. 69. 




Monocalcium phosphate crystals. 

The reaction of the urine and the solubility of the deposit in 
acids will distinguish phosphates from anything else. 

Calcium Carbonate. — This is frequently found in amrno- 
■ niacal urine in the form of very small colorless granules or 
dumb-bells. The effervescence with a drop of acid will 
identify it (Fig. 70). 

Cystin. — This is a very rare urinary deposit. It occurs 
most often in small six-sided plates with a " mother-of-pearl " 
appearance, or in the form of four-sided square prisms 
(Fig. 71). 

15— C. D. 



226 



URINARY SEDIMENTS. 



Xanthin. — This is found very infrequently, and occurs in 
the form of small fusiform crystals. 

Leucin and Tyrosin. — These are very rare, being found 



Fig 70. 



8 d 








^ 



Calcium carbonate crystals. 



Fig. 71. 







Vl 



& 




>^ 



O 



a, Crystals of xanthin (Salkowski; b, crystals 
of cystin (Robin). 



only in severe diseases of the liver. Leucin occurs in 
mulberry-like masses. Tyrosin appears as very fine needles 
arranged in the form of sheafs. Both are insoluble in alco- 



Fig. 72. 




Tyrosin crystals. (Charles.) 



hol or ether, readily soluble in acids, alkalies, or warm water 
(Figs. 72 and 73) 

Organized Sediment. — Red blood-corpuscles can usually 
be recognized under the microscope with the low power. 



URINARY SEDIMENTS. 



227 



If there is any doubt, the specimen should be covered with a 
cover-slip and a high dry power used. In freshly passed 
urine they usually show a light-yellow color and the typical 
biconcave appearance. If they have become shrunken, cre- 
nated, or the haemoglobin has become dissolved out, they 
may be recognized with difficulty. Only rarely are chemieal 
tests required. 

If a hemorrhage has occurred within the urinary tract, 
blood-clots may be found ; these may be moulded into more 
or less definite-shaped masses if formed within the tubules 



Fig. 73. 





Crystals of leucin (different forms) : (Crystals of kreatinin-zinc chloride resem- 
ble the leucin crystals depicted at a.) The crystals figured to the right consist of 
comparatively impure leucin. (Charles.) 

(blood-casts) or in the ureters ; but they are usually simply 
masses of clotted blood, especially if formed in the bladder. 

Leukocytes and Pus-cells. — A few leukocytes may be pres- 
ent in normal urine. An excess of leukocytes ov pus always 
indicates disease in some part of the urinary tract, except in 
the female, when the cells may be numerous as a result of 
contamination with vaginal discharge. In such cases they 
are associated with a corresponding increase in the vaginal 
epithelium. A catheterized specimen of urine should then 
be examined. 

The appearance of pus-corpuscles depends on the reaction 
of the urine. In acid and neutral urines they are usually 
well preserved ; but in alkaline urine they swell up, become 



228 UMNAHY SEDIMENTS. 

opaque, and the nucleus is recognized with difficulty, except 
after the addition of acetic acid. 

In pyogenic conditions the leukocytes are all polynuclear. 

The presence of a good many mononuclear leukocytes 
makes the presence of genito-urinary tuberculosis extremely 
suspicious. 

Pus can be most easily demonstrated by pouring off the 
greater part of the urine and adding a small piece of 
caustic soda or potash, when a viscid, sticky, slimy mass is 
formed. 

Epithelial cells occur in small numbers in the sediments of 
normal urine. An increased number of cells indicates an 
inflammatory condition in some part of the urinary tract. 
Unfortunately it is impossible to be absolutely certain as to 
which part of the urinary tract certain cells come from, since 
the cells from the bladder, ureters, and the pelvis of the 
kidneys are practically alike. Hence definite conclusions 
can very seldom be drawn from the microscopical examina- 
tion alone. 

Cells are of three kinds : 

(1) Round cells ; 

(2) Conical and caudate cells ; 

(3) Squamous, or pavement cells. 

Round cells are a trifle larger than leukocytes and have a 
more distinct nucleus. They may be confused with pus-cells, 
but in the latter it requires the addition of acetic acid to 
bring out the nucleus, which is furthermore polynuclear. In 
fatty degeneration of the kidney, fat can be demonstrated in 
these cells by means of Sudan III. 

Conical and caudate cells have their origin in the superfi- 
cial layers of the pelvis of the kidneys and the neck of the 
bladder ; the latter have the longer processes. 

Squamous or flat cells may come from the ureters, the 
bladder, the vulva and vagina of the female, and the prepuce 
of the male. They are large polygonal cells with a distinct 
nucleus and slightly granular protoplasm (Fig. 74). 

Tube-casts. — There are three main classes : 

(1) Hyaline and waxy casts. These are clear, almost 



URINARY SEDIMENTS. 



229 



transparent, homogeneous bodies ; they may be narrow or 
broad. There are also composite casts, chiefly hyaline, but 
more or less covered with granules and organized elements. 

(2) Those consisting of organized elements embedded in a 
hyaline matrix ; blood-casts, leukocyte casts, epithelial casts, 
bacterial casts. 

(3) Those consisting of the debris of organized bodies ; 
granular casts, fatty casts. 

Fig. 74. 




Cellular elements from the urine: 1, squamous epithelium ; 2, red blood-corpus- 
cles ; 3, polynuclear leukocytes; 4, transitional cells ; 5, epithelium from the kid- 
neys; 6, epithelium from the bladder; 7, Micrococcus urese ; 8, yeast-fungi. 
(Musser.) 



The inexperienced worker best recognizes and studies casts 
by comparing his microscopical preparation with good cuts. 

Casts usually indicate nephritis, acute or chronic ; but may 
be found in cases of renal calculi, icterus, diabetes, and some- 
times in secondary congestion of the kidney, and in fevers. 

Hyaline casts are clear, translucent cylinders, which are 
easily overlooked on account of their slight refraction of 
light. Their borders are clearly marked and their ends may 



230 



URINARY SEDIMENTS. 



be rounded or have a broken-off appearance ; they are seldom 
long, and are either straight or slightly curved. In diameter 
they vary from that of a white blood-cell (narrow) to five or 
six times this diameter (broad). It is seldom that they do 
not show some granulation. 

It is essential to have most of the light shut off when 
searching for these casts. 

Waxy casts are somewhat similar to hyaline, but have a 

Fig. 75. 




Hyaline casts from a case of acute nephritis : 1, plain hyaline cast; 2 granular 
deposit on hyaline cast ; 3, cellular deposit (blood and epithelium). (Musser.) 



light-yellow color, refract the light better, and are usually 
larger and seem more cylindrical. They have a waxy 
appearance (Fig. 75). 

Blood-casts consist most often of hyaline casts whose sur- 
face is covered with blood-cells, or of masses of blood-corpus- 
cles pressed into cylindrical shape. The same is true of 
epithelial and leukocyte casts (Fig. 76). 

Granular casts have as their basis the hyaline cast ; this 
is covered with fine or coarse granules, few or many, or 



URINARY SEDIMENTS. 



231 



is granular from a disintegration of the cast itself. The 
granules may be so coarse and numerous as to give the 
cast a dark appearance. Enormous numbers of coarse dark 
granular casts have, according to Dock, a grave prognostic 
indication. 

Fatty casts are simply hyaline or granular casts on which 
are deposited minute oil drops, or sometimes crystals of fat. 

Cylindroids resemble hyaline casts, except in shape and 

Fig. 76. 




a, Fatty casts ; b and c, blood-casts ; d, free fatty molecules. (Roberts.) 

size. They are much larger, and usually taper from a thick 
end to a slender wavy or twisted point, or they may show 
several constrictions in their course. They may have a 
striated or ribbed appearance (Fig. 77). They have practi- 
cally no pathological significance. 

False casts have been described. They consist of urinary 
crystals or amorphous salts moulded into cylindrical forms. 

Spermatozoa are easily recognized by their tadpole ap- 
pearance (Fig. 78), 



232 



URINARY SEDIMENTS. 

Fig. 77. 




a and b, cylindroids from the urine in congested kidney, (v. Jaksch.) 

Parasites — Vegetable and Animal. — Vegetable. — The 
bacteria of most importance in urinary examination are the 
gonococcus, the tubercle bacillus, and the colon bacillus and 
typhoid bacillus. 



URINARY SEDIMENTS. 



233 



Clap-threads may be fished out of freshly passed urine or 
the urine may be centrifugated, and spreads made of the 
sediment, dried in the air, and fixed in a flame. These are 
now stained with methylene-blue solution or by Gram's 
method or with neutral red or Kresylechtviolett. 

Tubercle Bacillus. — Any opaque particles are fished out 
of the suspected urine, or it is centrifugated and spreads 
made, dried, and fixed as above. The specimen is then 
double-stained with carbol-fuchsin and methylene-blue, as in 
sputum examination. Tubercle bacilli in the urine are often 

Fig. 78. 




Human semen : a, spermatozoa ; b, cylindrical epithelium ; c, bodies enclosing' 
lecithin-granules ; d, squamous epithelium from the urethra ; d', testicle-cells ; 
e, amyloid corpuscles ; /, spermatic crystals ; g, hyaline globules, (v. Jaksch.) 



arranged in thick masses, having an S-shaped form. It may 
be difficult to demonstrate the germs by staining methods. 
The urine is then sedimented, and 1 or 2 c.c. of the sediment 
injected into the peritoneal cavity of a guinea-pig. In the 
course of six weeks the pig should develop tuberculosis if 
the urine contains tubercle bacilli. The pig is posted, and 
tubercles found in the various organs of the abdomen and 
perhaps chest. 

Smegma Bacillus. — This is important because it resembles 
the tubercle bacillus very closely in its morphology and stain- 
ing characteristics. It is found on the external genitals of 



234 URINARY SEDIMENTS. 

both sexes, and at times in the urethra. It may find its wav 
into the urine and faeces, and thus be mistaken for the tuber- 
cle bacillus. It does not cause disease ; hence animal inocula- 
tion is a certain means of differentiating the two germs. 

They can also be differentiated by Pappenheim's method of 
differentiating Bacillus tuberculosis from the smegma bacillus. 
The specimen is stained with carbol-fuchsin solution : then 
after draining off the excess of stain, it is dipped from three 
to five times into Pappenheim's solution (1 part of corallin 
(rosolic acid) in 100 parts of absolute alcohol, to which 
methylene-blue is added to saturation. This mixture is 
treated further with 20 parts of glycerin). The specimens 
are washed in water, dried between filter-paper, and mounted . 
in Canada balsam. The tubercle bacilli are stained red, and 
all other germs, including smegma bacilli, are stained blue. 

A simpler method of differentiation is to stain with carbol- 
fuchsin, decolorize in 33 per cent, nitric acid, then wash in 
95 per cent, alcohol for thirty seconds, and counterstain with 
methylene-blue. Smegma bacilli hold the red color in the 
presence of acids, but not in the presence of alcohol. 

Gonococci. — (1) Stain by Gram's method (see page 19), 
then counterstain with dilute carbol-fuchsin 1 : 8, without 
heat, or with saturated aqueous solution of Bismarck-brown 
with heat to the steaming-point, Wash in water and mount. 
Diplococci within leukocytes, which have been decolorized 
by Gram's stain, and have taken the counterstain of red or 
brown, are to be considered as gonococci. 

(2) Neutral Red Stain. — This is an excellent stain. In a 
dilution of about 1 : 15,000 it shows a selective action for gono- 
cocci, staining them a red color, while other organisms, with 
the exception of the Diplococcus urethra communis, which 
takes a somewhat lighter red, remain unstained. Morse 
gives the following directions : 

1. Make a stock 1 per cent, aqueous solution of neutral red. 

2. To a beaker of distilled water add sufficient of this 
stock solution to give a sherry-wine color (about 1 : 15,000). 

3. Float fixed spread, specimen side down, upon this solu- 
tion for about five minutes. 



URINARY SEDIMENTS. 



235 



4. Wash quickly in distilled water and dry with filter- 
paper. 

(3) Methylene-blue. — With this stain the diplococci within 
the leukocytes are usually considered as gonococci. The 
stain is easily applied, but is not specific, as all cocci in the 
preparation take the same blue stain. 

Gram and Neutral Red Stain for Gonococci (Morse) : 
10 c.c. water ; 2 c.c. anilin oil ; shake ; filter clear. Add 
1 c.c. alcohol and 1 c.c. saturated gentian-violet solution. 

Fig. 79. 







A gonorrhoea! thread. (Simon.) 

1. Stain in this cold for two minutes. 

2. Leave in Gram's (I in KI) solution for three minutes. 

3. Wash in alcohol till decolorized. 

4. Wash in water. 

5. Float in neutral red solution 1 : 5000 about five minutes. 

6. Dip once in distilled water and dry with filter-paper. 
As is well known, certain bacteria are stained by Gram's 

stain, while others are not (see Gram's stain). The Diplococ- 
cus urethrse communis resembles the gonococcus very closely in 
its morphology ; it is a little larger and longer. The average 
observer is likely to mistake it for the gonococcus. It is 
stained by the Gram method, while the gonococcus is not. 
The above stain will differentiate these two organisms. 

Bacteriuria is the name given to a condition in which 



236 URINARY SEDIMENTS. 

micro-organisms are present in considerable numbers in 
urine at the time of voiding. These can be demonstrated by 
preparing the sediment, fixing, and staining with methylene- 
blue. 

The bacteria of the infectious diseases can sometimes be 
demonstrated by appropriate methods of culture and staining. 

The trichomonas is rarely found in the urine. 

Sarcines, yeasts, and moulds are rarely found. 

Animal parasites are rarely found, and then chiefly in resi- 
dents of the tropics. 

Among them are the echinococcus, Filaria sanguinis 
hominis, Bilharzia hsematobia, Distoma haematobium, Stron- 
gylus gigas. 

Calculi. — Examination of the freshly passed urine may 
throw considerable light upon the nature of the calculus. 
Small crystalline masses, gravel, or deposits of uric acid or 
calcium oxalate may be seen. If the urine is distinctly acid 
at the time the gravel was passed or the attack of renal colic 
occurred, it is almost certain that the calculus is either uric 
acid or calcium oxalate; in a large percentage of the cases 
the former, especially if directly on cooling the urine precipi- 
tates crystals of uric acid. If the fresh urine shows con- 
tinually the presence of crystals of calcium oxalate, it is most 
likely a calcium oxalate calculus. 

In alkaline urines the calculus is usually of the mixed 
phosphate variety, or has a nucleus composed of uric acid or 
calcium oxalate and coated with phosphates. 

Accidental Substances. — Extraneous matter found in the 
urine may consist of fibres of various kinds, such as cotton, 
linen, or woollen ; starch-granules or oil drops, or particles 
of dust. These may appear in the urine as a result of con- 
tamination with towels, clothing, toilet preparations, dust, etc. 

CRYOSCOPY. 

Molecular Concentration of the Urine. — The method 
of determining the freezing-point of the urine is the same as 
that for the blood. 



URINARY SEDIMENTS, 237 

Lenhartz gives the following statement of the value of 
eryoscopy in the examination of urine : " In defective renal 
function and consequent retention in the blood of substances 
which should be excreted in the urine, a diminution of the 
molecules in the urine must occur in the same ratio. In other 
words, in disturbed renal function the freezing-point of the 
urine (J) rises above the normal. 

"It has been shown that in healthy kidneys this varies be- 
tween 0.87° and 2.42° C, according to the conditions of metab- 
olism. In order to obtain an approximate idea of the actual 
amount of molecules excreted, the daily amount of urine must, 
of course, be considered. In order to obtain standard values, 
the product of A and the amount of urine = V (valence 
number) has been calculated. The figures given by different 
authorities vary between 766 and 3770. While, the practical 
value of the molecular determination of the urine in internal 
medicine is limited (because the limits of the normal value, 
which among other things are decidedly influenced by solid 
and liquid foods, are very variable) the researches of Kummel 
and Rumpel have shown that eryoscopy is of the greatest 
advantage in the diagnosis of unilateral renal affections. For 
this purpose it is necessary to collect the urine of both kidneys 
separately by ureteral catheterism. The urine of each kidney 
is then examined in regard to its freezing-point and also its 
urea and sodium chloride content. If A of one kidney shows 
a normal value, while A of the other kidney is under 0.87° C, 
this indicates an affection of the latter." 

The foregoing remarks indicate that the value of eryoscopy 
is extremely limited, as the members of the profession who 
are thoroughly familiar with ureteral catheterism in the male, 
and the technique of eryoscopy will always be very few and 
confined to the larger medical centres. 

QUESTIONS. 

What points are to be noted in the naked-eye examination of urine ? 
Describe the correct method of making a microscopical examination of 
urine. 

Classify urinary sediments. 

What substances are most commonly found in chemical sediments? 



238 VRIKARY SEDIMENTS. 

What substances are rarely found ? 

Mention the important points in the law of crystalizatiou. 

Describe the various forms of uric acid crystals. 

Describe the various forms of urates. 

Mention several simple tests for the detection of urates. 

Describe the common form of calcium oxalate crystals. 

Describe the various forms of phosphates. 

Describe calcium carbonate, cystin, xanthin, leucin, and tyrosin crystals. 

Describe the red blood-corpuscles in varying conditions of the urine. 

Give several methods for recognizing pus in the urine. 

Of what significance is an excess of mononuclear leukocytes in the urine? 

Name the different areas of the urinary tract in which similar cells are 
fuund. 

Mention the chief classes of tube casts. 

In what conditions are tube casts found, and what is their significance ? 

Describe cylindroids. False casts. 

Describe the various methods of demonstrating tubercle bacilli in the 
urine. 

Describe a differential stain for the gonococcus. 

What is meant by bacteriuria ? 

Of what value is sediment examination in determining the nature of 
calculi ? 

Mention accidental substances found in urinary sediments. 



INDEX. 



ACETIC acid and heat-test for albu- 
min, 198 
Acetone, 186 

tests for, 208 
Achlorhydria, 129 
Acid, combined hydrochloric, 117 

free hydrochloric, tests for, 116 

lactic, 116, 117 

organic, 116, 117 
Actinomycosis, 159 
Albumin in urine, 184, 185 

quantitative estimation of, 202 

tests for, 197-203 

varieties of, 184, 185 
Albuminuria, mixed, 185 
Albumose, 185 

tests for, 202, 203 
Alexins, 99 
Alizarin solution, 105 
Amoeba coli, 137, 138 
Anchylostoma duodenale, 144 
Aniline water, 19 
Animal inoculation, 164 
Apepsia, 129 
Appendicitis, 100 
Articular fluid, 167 
Ascaris lumbricoides, 143 

BABCOCK fat tester, 169 
Bacillus pneumoniae of Fried- 
lander, 158 
Bacteremia, 93 
Bacteriological clinical examinations, 

163 
Bacteriuria, 189, 235, 236 
Barium chloride solution, 172 
Basophilia, punctate, 61 
Bile, tests for, 209 
Biuret reaction, 202 
Blood, 21-104 

agglutinins of, 30 
alkalinity of, 68 
bacteriology of, 72 



Blood, chemical analysis of, 30, 31 
clinical examination of, 34, 35 
coagulation of, 30, 69 
color of, 29 

index of, 41 
counter, Turck's, 45 
counting fluids, 25, 26 

red corpuscles of, 42, 43, 44 

white corpuscles of, 45, 46, 47 
cryoscopy of, 70, 71 
diseases of, 72-93 

ansemia, aplastic, 75 

primary pernicious, 72, 73, 74 
secondary, 76 
pernicious, 74, 75 

chlorosis, 76 

differential diagnosis in, 79, 80 

Hodgkin's disease, 79 

iodophilia, 80 

leukaemia, 77, 78, 79 

splenomegaly, 79 
dust, 32 

fibrin network, 33 
fixing spreads of, 50, 51 
fresh drop examination of, 35, 36 
guaiacum test for, 21 
haBmin test for, 21 
hsemoglobin, 30 

estimation of, 36-40 
method of securing, 35 
physiology of, 31 
pigment granules, 30 
pipettes, cleaning of, 23-25 
plates, 32, 53 
reaction, 29 

abnormal forms of red corpuscles 
of, 31, 52, 55, 61 
serum, 30 

specific gravity of, 31, 41, 42 
spreads or films, making, 48-50 
staining with Wright's stain, 51-54 

with Ehrlich's tricolor mixture, 
54-56 

239 



240 



INDEX, 



£U ood staining with eosin and hsemo- 
toxylon, 56, 57 

stains, 26-28 

stickers, 23 

total volume of, 29, 69 

white corpuscles of, 31 

work, technique of, 23-25 
Boas sieve, 132 

test-breakfast, 109 
Boston's test for albumin, 199 
Bothriocephalus latus, 141, 142 
p-oxybutyric acid, 186, 209 

CALCIUM oxalate, 223 
Calculi, urinary, 189, 236 
Cammidge's pancreatic test, 211-214 
Carbol fuchsin, 19 
Casts in urine, 187 

Centigrade and Fahrenheit conver- 
sion, 23 
Cercomonas intestinalis, 138 
Cerebrospinal fluid, examination of, 166 
Cestodes, 138, 139 
Charcot-Leyden crystals in faeces, 135 

in sputum, 162 
Chlorides in urine, 182. 195 
Chyluria, 190 
Clap threads, 188 
Color index, 41 
Congo-red test, 116 
Cream gauge, 169 
Cryoscopy, 70, 71, 236, 237 
Crystallization, laws of, 219, 220 
Crystals in faeces, 135 

in urine, 189 
Culture media, 163 
Curschmann's spirals, 153 
Cylindroids, 188 

DARE'S haemoglobinometer, 40, 41 
Decinormal sodium hydrate solu- 
tion, 105 
Degeneration of red blood-cells, endo- 
globular, 60 
granular, 61 
Delah* eld's hsematoxylon, 27 
Diabetic coma, 186 
Diacetic acid, 186, 208 
Diazo reaction of Ehrlich, 186, 210 

solutions, 171 
Dimethylamido-azobenzol solution, 105 
Diphtheria bacillus, 164 
Diplococcus intracellulars meningiti- 
dis, 165 
pneumoniae, 158 



Distoma pulmonale, 161 
Doremus ureometer, 194 
Dumdum fever, 92 
Durham's heematocytometer, 48 

ECHINDCOCCUS cysts, 160 
Ehrlich's dahlia solution, 28 
diazo reaction, 171, 186, 210 
tricolor mixture, 27 

Elastic tissue in sputum, 155 

Endocarditis, malignant, 93 

Eosin, 27 

Eosinophilia, 103, 104 

Erythrocytes, 31 (see Red blood-cor- 
puscles). 

Esbach's albuminimeter, 202 
reagent, 171 

Ethereal extracts, 20 

Euchlorhydria, 129 

Eupepsia, 129 

Ewald and Boas test-breakfast, 108 

Exudates, 167 

FAECES, 130-147 
amount of, 130 

bacteria in, 135-137 

bacteriological examination of, 136 

blood in, 133 

color of, 130, 131 

consistence of, 130, 131 

crystals in, 135 

fat in, 133 

macroscopical examination of, 131, 
132 

method of obtaining specimen of, 
133, 134 

microscopical examination of, 133, 
135 

mucus in, 132 

odor of, 130 

parasites in, 137-146 

pus in, 133 
Fat, detection of, 20 

estimation of, 168, 169 

in urine, tests for, 211 
Fehling's solution, 171 

test, 203 
Fermentation test for sugar, 201 
Ferric chloride solution, 172 
Ferrocyanide of potassium solution, 

172 
Feser's lactoscope, 168 
Fibrinous casts, 152 
Ficker's typhoid diagnosticum, 66 
Filariasis, 90 



INDEX. 



241 



Fleischl's hsemoglobinometer, 36 
Foam test for bile, 209 
Fungi in urine, 189 

GABBETT'S stain, 157 
Gall-stones, 132 
Gastric analysis, 104-129 

apparatus required for, 104-106 
reagents required for, 105 
short method of, 120 
Topfer's method of, 117-120 
juice, analysis of, 108, 116 
Gentian violet, 19 
Gerhardt's test for diacetic aoid, 208 
Glassware, cleaning of, 18 
Gmelin's test for bile, 209 
Gonococci, methods of staining, 234 

235 
Gower's fluid, 26 
Gram's stain, 19 
Gunzburg's reagent, 105 
test, 116 

HEMATOCRIT, Daland's, 68 
Hematuria, 187 
Hsemocytometer, Oliver's, 68 
Haemoglobin, 36-41 
estimation of, with Dare's hsemo- 
globinometer, 41 
with Fleischl's hsemoglobinom- 

eter, 36-39 
with Miescher's hsemoglobinom- 

eter, 39, 40 
with Oliver's hemoglobin oineter, 

40,41 
with Tallqvist's scale, 36 
Haeser's coefficient, 193 
Haine's sugar test, 204 
Hammerschlag's method of estimat- 
ing pepsin, 124 
Hayem's fluid, 26 
Heart-failure cells, 162 
Heat and nitric acid test for albumin , 197 
Pleller's ring test, 198 
Helminthiasis, 103 
Holt's cream gauge, 169 
Horismoscope, 199 
Hyperchlorhydria, 129 
Hyperpepsia, 129 
Hypobromite solution, 172 
Hypochlorhydria, 129 
Hypopepsia, 129 

TNDICAN, 181, 209, 210 
1 Indol, 130, 180 

16— C. P. 



Influenza bacillus, 158 
Iodine test for bile, 209 

for starch, 20 
Iodophilia, 28, 57 

JAFFE'S test for indican, 209, 210 
Jaundice, 186 
Jenner's stain, 53, 54 
Jolle's ferrometer, 40 

KARYOKINESIS, 62 
Kelling's test for lactic acid, 116 
Klebs-Loffler bacillus, 164 

LABORATORY supplies, 17, 18 
Lactic acid, 116, 117 

Kelling's test for, 116 
Strauss' test for, 117 
Uflelmann's test for, 116 
Lactodensimeter of Quevenne, 169 
Lactoscope of Feser, 168 
Lactose in urine, 186 
Legal' s test for acetone, 208 
Leishman-Donovan parasite, 92 
Leptothrix buccalis, 159 
Leukocytes, 31, 57, 58, 59 
degeneration of, 62, 63 
differential counting of, 59 
diluting fluid for counting of, 26 
table of, 47 
varieties of, 52-60 

eosinophile, 52, 56, 59 

large mononuclear, 52, 55 

lymphocyte, 52, 55 

mast cell, 52, 56, 59 

melaniferous, 90 

myelocyte, 53, 58, 59, 60 

normal percentage of each variety 

in the adult, 96 
polynuclear, 52 
transitional, 55 
Leukocytosis, 96-104 
chemotactic theory of, 98, 99 
in appendicitis, 100 
inflammatory and infectious, 100 
in malignant disease, 102 
of digestion, 97 
of pregnancy, 97 
pathological, 98 
post-hemorrhagic, 99 
therapeutical and experimental, 102 
varieties of physiological, 97, 98 
Leukopenia, 93, 94, 95 
in tuberculosis, 94 
in typhoid fever, 95 



242 



INDEX. 



Leukopenic phase, 99 
Lieben's test for acetone, 208 
Loffler's methylene-blue, 19 
Lohnstein's urinometer, 175 
Lugol's solution, 19, 172 
Lumbar puncture, 166 
Lymphatic leukaemia, 102, 103 
Lymphocytosis, 102 

MALAEIA, 80-90 
leukocytes, melaniferous, in, 90 
melansemia in, 90 
parasites of, 53, 80-90 
sestivo-autumnal, 89 
crescentic bodies, 89 
double tertian, 88 
flagellation in, 88 
fragmentation in, 87 
presegmenting bodies, 87 
quartan, 88 
ring forms, 87 
signet ring, 89 
spheroidal bodies, 87 
staining the malarial parasite, 81, 

86 
tertian, 86-88 
Megaloblast, 61 
Megalocyte, 61 
Methylene-blue, 19, 27 
Metrocyte, 62 
Mett method of determining peptic 

digestion, 121-123 
Microblast, 61 
Microcyte, 61 

Miescher's haernoglobinorneter, 39 
Milk, average cows', 168 
human, 168 
examination of, 168, 169 
specific gravity of, 169 
Mucous colitis, stools in, 132 

threads in urine, 188 
Mucus in faeces, 132 
Murexid test for uric acid, 195 

NEMATODES, 142, 143 
Neusser's basophilia, 63 
Neutral red stain for gonococci, 234, 

235 
Nocht-Romanowsky stain, 28 
Normoblast, 61 
Nucleo-albumin, 185 

OIDIUM albicans, 160 
Oliver's hsemoglobinometer, 40 
Oppler-Boas bacillus, 115 



Oxalic acid and oxalates, 183 
Oxyuris vermicularis, 143 

PANCREATIC diseases, urine test 
for, 211-214 
Pappenheim's stain, 234 
Parasites in blood, 80-93 

in fseces, 135-146 

in sputum, 159-161 

in urine, 189 
Peptic digestion tests, 121-125 
Peptone, 185 

Pertussis, lymphocytosis in, 103 
Phagocytosis, 99 
Phenol, 180 

Phenolphthalein solution, 105 
Phenylhydrazin test, 204 
Phosphates, 181, 182 
Plasmodium malaria, 53, 80-90 
Plate cultures, 163 
Poikilocytosis, 60 
Polari scope, 207 

Potassium ferrocyanide test for albu- 
min, 202 

hydrate solution, 172 
Proteids, tests for, 124, 125 
Protozoa, 137, 138 
Purdy's solution, 171 

sugar test, 205, 206, 207 
Purulent affections, blood in, 80 
Pyroplasma hominis, 92 



Q 



UEVENNE'S lactodeusimeter, 169 



RED blood-corpuscles, abnormal 
forms of, 61, 62 
Relapsing fever, 90 
Rennet, tests for, 124 
Riegel test-dinner, 109 
Rocky Mountain tick, 92 
Rosenbach's test for bile, 209 

SACCHARIMETER of Einhorn or 
Lohnstein, 205 
Sarcinae, 115 
Serum globulin, 184, 185 
Silver nitrate solution, 172 
Simon's modification of Heller's test, 

200, 201 
Skatol, 130 
Sleeping sickness, 91 
Smegma bacillus, differential stain of, 

233 
Sodium hydrate solution, 173 



INDEX. 



243 



Spermatozoa, 188 
Spirochseta Oberrneieri, 90 
Spotted fever, 92 
Sputum, 147-163 
amoeba coli in, 100 
animal parasites in, 160 
apparatus for examination of, 147 
cheesy particles in, 152 
color of, 150 
consistence of, 150 
crystals in, 162 
epithelial cells in, 161 
examination of, 149 
leukocytes in, 161 
macroscopical examination of, 150 
method of obtaining, 148 
microscopical examination of, 154 
odor of, 150 
red blood-cells in, 161 
slide, author's, 149 
spreading of, 149 
staining of, 156 
stains and reagents for examination 

of, 147 
trichomonades in, 160 
varieties of, 152 

crudum, 152 

globosum, 152 

mucoid, 152 

mucopurulent, 152 

mucoserous, 152 

nummular, 152 

purulent, 152 

sanguineous, 152 

sanguinomucopurulent, 152 

serosanguineous, 152 

serous, 152 
vegetable parasites in, 156 
Squibb' s urinometer, 175 
Stains, 19, 20 

analine water gentian -violet, 19 
carbol fuchsin, 19 
dahlia solution of Ehrlich, 28 
eosin, 27 

and methylene-blue, 27 
Gram's, 19 

hsematoxylon, Delaneld's, 27, 56 
Hewes' after-stain, 54 
iodophilia mixture, 28, 80 
Jenner's, 53, 54 
Loffler's methylene-blue, 19 
Leish man's, 53, 54 
Lugol's solution, 19 
neutral red, 234 
Nocht-Romanowsky, 28 



Stains, Pappenheim's, 234 

Sudan III., 20 

thionin, 86 

tricolor mixture of Ehrlich, 27, 54 

Wright's, 26, 81 
Starch, iodide test for, 20 

iodine test for, 20 
Stomach, 104-129 

absorptive power of, 128 

contents, examination of, 114-120 

motor power of, 127, 128 

size, shape, and position of, 128, 129 
Stomach-tube, contra-indications to 
the use of, 110 

method of use, 111-113 
Strauss' test for lactic acid, 117 
Streak method of bacteriological ex- 
amination, 164 
Streptococci and staphylococci in spu- 
tum, 159 
Streptothricosis, 159 
Sudan III., 20, 172 
Sugar in the urine, 85 

tests for, 202-208 
Sulphates, 180 

tests for, 196 

TAENIA saginata, 139 
solium, 141 
Tallqvist's haemoglobin scale, 36 
Test-meals, 108-110 
Thrush, 160 {see Oidium albicans). 
Toisson's fluid, 25 
Topfer's method of gastric analysis, 

117 
Transudates, 167 
Trapp's coefficient, 193 
Trichina, 146 

Trichomonas intestinalis, 138 
Triple phosphate, 182 
Trypanosomiasis, 91 
Tubercle bacillus, 156 

in fseces, 136, 137 

in sputum, 156 

in urine, 233 
methods of staining, 156, 157 
Tiirck's blood-counter, 45 
Typhoid fever, 93 

UFFELMANN'S test, 116 
Uncinaria duodenalis, 114 {see 
Anchylostoma duodenale). 
Uncinariasis, examination of fseces in, 

146 
Urate of ammonium, 22£ 



244 



INDEX. 



Urate of sodium, 222 
Urates, 222 
Urea, 177, 178 

estimation of, 194 
Uric acid, 179, 195 

crystals, 221 
Urinalysis, value of, 173 
Urinary sediments, 215-236 
calcium carbonate, 225 

oxalate, 223, 224 
casts, 228-231 
blood, 230 
fatty, 231 
false, 231 
granular, 230 
hyaline, 229 
waxy, 230 
chemical, 218 
classification of, 218 
cylindroids, 231 
cystin, 225 
epithelial cells, 228 
leucin, 226 
leukocytes, 227 

macroscopical examination of, 215 
microscopical examination of, 216- 

218 
organized, 226-236 
phosphates, 224, 225 
pus-cells, 227 
triple phosphates, 224 
ty rosin, 226 
urates, 222 
uric acid, 221 
xanthin, 226 
Urine, 170-238 

accidental substances in, 236 

acetone in, 186 

albumins in, 184, 185 

amount of, 174 

apparatus used in examination of, 

170, 171 
bacteria in, 189 
bile in, 186 
blood in, 187, 211 
/3-oxybutyric acid in, 186 
calculi in, 189 
carbohydrates in, 185 
casts in, 187 

characteristics of normal, 173-176 
chlorides in, 182 
clap threads in, 188 
color of, 175, 176 



Urine, constituents of normal, 176-183 
cryoscopy of, 236, 237 
crystals in, 189 
cylindroids in, 188 
diacetic acid in, 186 
epithelium in, 188 
examination of, 191 
fat in, 190 

foreign matter in, 190 
freezing-point of, 236, 237 
fungi in, 189 
haemoglobin, 185 
leukocytes in, 187 
lymph in, 190 
mucous threads in, 188 
odor of, 176 
oxalic acid in, 182, 183 
parasites in, 189, 232-236 
pathological substances in, l^oH'l 
phosphates in, 181, 182 
pus in, 187 
reaction of, 175 
reagents used in examination of, 

171, 172 
scheme for recording examinations 

of, 192 
specific gravity of, 174, 175 
spermatozoa in, 188 
sulphates in, 180, 181 
tissue debris in, 188 
total nitrogen in, 180 

solids, determination of, 198, I'M 
turbidity of, 173, 176 
worms in, 190 

VEGETARIANS, stools of, 131 



WELSH'S capsule stain. 158 
Weights and measures, tablt of, 

22 
Widal reaction. 64-67 
Worms. 138, 135) 

in urine, 190 
Wright's method of counting leuko- 
cytes, 47. 18 
stain, 26 

VAXTHIX bodies, 179 



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